Provider Demographics
NPI:1588732523
Name:EASTERN IDAHO CHIROPRACTIC CLINIC PA
Entity type:Organization
Organization Name:EASTERN IDAHO CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC NATUROPATHIC MEDICAL
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DCNMD
Authorized Official - Phone:208-522-0200
Mailing Address - Street 1:2585 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7516
Mailing Address - Country:US
Mailing Address - Phone:208-522-0200
Mailing Address - Fax:208-523-6051
Practice Address - Street 1:2585 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7516
Practice Address - Country:US
Practice Address - Phone:208-522-0200
Practice Address - Fax:208-523-6051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010020547OtherBLUE SHIELD INSURANCE
IDC9453OtherBLUE CROSS INSURANCE
IDC9453OtherBLUE CROSS INSURANCE
ID1672597Medicare ID - Type Unspecified