Provider Demographics
NPI:1891985826
Name:BACK COUNTRY CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:BACK COUNTRY CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:CLEMENT
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-624-2222
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-0586
Mailing Address - Country:US
Mailing Address - Phone:208-624-2222
Mailing Address - Fax:208-624-2220
Practice Address - Street 1:104 N BRIDGE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-1455
Practice Address - Country:US
Practice Address - Phone:208-624-2222
Practice Address - Fax:208-624-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1145111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010154569OtherREGENCE BS
ID1369096OtherGROUP PRICING NUMBER
IDC9670OtherBC OF IDAHO
ID1670479OtherPERFORMING PROVIDER NUMBE
ID1369096OtherGROUP PRICING NUMBER