Provider Demographics
NPI:1104055383
Name:SIRUCEK, MARIA TERESA GOMEZ (DC)
Entity type:Individual
Prefix:DR
First Name:MARIA TERESA
Middle Name:GOMEZ
Last Name:SIRUCEK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 E GENTRY WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3544
Mailing Address - Country:US
Mailing Address - Phone:208-345-7262
Mailing Address - Fax:208-343-1953
Practice Address - Street 1:3080 E GENTRY WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3544
Practice Address - Country:US
Practice Address - Phone:208-345-7262
Practice Address - Fax:208-343-1953
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1370111N00000X, 111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1093975302Medicaid
ID1093975302Medicaid