Provider Demographics
NPI:1316117005
Name:MNA GIBSON P.C.
Entity type:Organization
Organization Name:MNA GIBSON P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-896-5520
Mailing Address - Street 1:3536 E TALLOW LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-7092
Mailing Address - Country:US
Mailing Address - Phone:208-921-1781
Mailing Address - Fax:208-896-9920
Practice Address - Street 1:7A REICH ST.
Practice Address - Street 2:
Practice Address - City:MARSING
Practice Address - State:ID
Practice Address - Zip Code:83639
Practice Address - Country:US
Practice Address - Phone:208-896-5520
Practice Address - Fax:208-896-9920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1130111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty