Provider Demographics
NPI:1588921654
Name:ORCHARD CHIROPRACTIC, INC
Entity type:Organization
Organization Name:ORCHARD CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:ORCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-656-8883
Mailing Address - Street 1:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0456
Mailing Address - Country:US
Mailing Address - Phone:208-656-8883
Mailing Address - Fax:208-656-8883
Practice Address - Street 1:160 VALLEY RIVER DR STE 3
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5313
Practice Address - Country:US
Practice Address - Phone:208-656-8883
Practice Address - Fax:208-656-8883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1002111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM8063862Medicaid
ID000010159874OtherBLUE SHIELD
IDC9905OtherBLUE CROSS
ID000010159874OtherBLUE SHIELD
IDC9905OtherBLUE CROSS