Provider Demographics
NPI:1194873471
Name:BLUE MTN CHIROPRACTIC
Entity type:Organization
Organization Name:BLUE MTN CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-846-8400
Mailing Address - Street 1:280 E CORPORATE DR
Mailing Address - Street 2:STE 130
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2951
Mailing Address - Country:US
Mailing Address - Phone:208-846-8400
Mailing Address - Fax:
Practice Address - Street 1:280 E CORPORATE DR
Practice Address - Street 2:STE 130
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2951
Practice Address - Country:US
Practice Address - Phone:208-846-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty