Provider Demographics
NPI:1194975250
Name:MARY JO WHITE DCPA
Entity type:Organization
Organization Name:MARY JO WHITE DCPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE DCPA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-777-2884
Mailing Address - Street 1:606 N SPOKANE ST
Mailing Address - Street 2:STE C
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5291
Mailing Address - Country:US
Mailing Address - Phone:208-777-2884
Mailing Address - Fax:208-777-0277
Practice Address - Street 1:606 N SPOKANE ST
Practice Address - Street 2:STE C
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5291
Practice Address - Country:US
Practice Address - Phone:208-777-2884
Practice Address - Fax:208-777-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA713111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1368400Medicare PIN