Provider Demographics
NPI:1407215668
Name:ENSO CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:ENSO CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER / CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:DARREL
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-887-4747
Mailing Address - Street 1:3313 W CHERRY LN
Mailing Address - Street 2:PMB 703
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1119
Mailing Address - Country:US
Mailing Address - Phone:208-887-4747
Mailing Address - Fax:208-887-4657
Practice Address - Street 1:903 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2301
Practice Address - Country:US
Practice Address - Phone:208-887-4747
Practice Address - Fax:208-887-4657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1703111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty