Provider Demographics
NPI:1154938983
Name:BODY OF A CHAMPION CHIROPRACTIC, PC
Entity type:Organization
Organization Name:BODY OF A CHAMPION CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MADISON
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-990-7010
Mailing Address - Street 1:9196 W EMERALD ST STE 120
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8003
Mailing Address - Country:US
Mailing Address - Phone:208-990-7010
Mailing Address - Fax:
Practice Address - Street 1:9196 W EMERALD ST STE 120
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8003
Practice Address - Country:US
Practice Address - Phone:208-990-7010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty