Provider Demographics
NPI:1427242734
Name:IDAHO SPINE AND SPORTS CHIROPRACTIC INC
Entity type:Organization
Organization Name:IDAHO SPINE AND SPORTS CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDRICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:TWEEDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-323-2833
Mailing Address - Street 1:2399 S ORCHARD ST
Mailing Address - Street 2:STE. 204
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3793
Mailing Address - Country:US
Mailing Address - Phone:208-323-2833
Mailing Address - Fax:208-323-2834
Practice Address - Street 1:2399 S ORCHARD ST
Practice Address - Street 2:STE. 204
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3793
Practice Address - Country:US
Practice Address - Phone:208-323-2833
Practice Address - Fax:208-323-2834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty