Provider Demographics
NPI:1306900733
Name:MITCHELL, SAM (DC)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:SAMUEL
Other - Middle Name:DAVID
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:10316 USTICK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5284
Mailing Address - Country:US
Mailing Address - Phone:208-376-4364
Mailing Address - Fax:
Practice Address - Street 1:10316 USTICK RD STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5284
Practice Address - Country:US
Practice Address - Phone:208-376-4364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1050111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC4165OtherBLUE CROSS