Provider Demographics
NPI:1043481351
Name:CHARLES GREEN CHIROPRACTOR
Entity Type:Organization
Organization Name:CHARLES GREEN CHIROPRACTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-429-8085
Mailing Address - Street 1:7683 W RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-6188
Mailing Address - Country:US
Mailing Address - Phone:208-429-8085
Mailing Address - Fax:
Practice Address - Street 1:7683 W RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-6188
Practice Address - Country:US
Practice Address - Phone:208-429-8085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC-534111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty