Provider Demographics
NPI:1992706741
Name:PAGE, TIMOTHY LEE (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:LEE
Last Name:PAGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:TIMOTHY
Other - Middle Name:LEE
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:476-1/2 E.CHUBBUCK RD.
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202
Mailing Address - Country:US
Mailing Address - Phone:208-478-7243
Mailing Address - Fax:208-237-0712
Practice Address - Street 1:476-1/2 E.CHUBBUCK RD.
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202
Practice Address - Country:US
Practice Address - Phone:208-478-7243
Practice Address - Fax:208-237-0712
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2011-07-05
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-974111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID350055267OtherRAILROAD MEDICARE
ID350055267OtherRAILROAD MEDICARE