Provider Demographics
NPI:1962542332
Name:MARICICH, MARIA M (DC)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:M
Last Name:MARICICH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:L
Other - Middle Name:MARIA
Other - Last Name:MARICICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 6459
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340
Mailing Address - Country:US
Mailing Address - Phone:208-726-6010
Mailing Address - Fax:208-726-6010
Practice Address - Street 1:131 4TH ST. E, SUITE 310
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-726-6010
Practice Address - Fax:208-726-6010
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC622111N00000X
IDCHIA622111NN1001X, 111NI0900X, 111NP0017X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
No111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC622-8OtherBLUE CROSS
ID0000-1002-0870OtherBLUE SHEILD