Provider Demographics
NPI:1073630984
Name:BLY, GRETCHEN MICHELLE (DC)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:MICHELLE
Last Name:BLY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:MICHELLE
Other - Last Name:DILLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:105 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2634
Mailing Address - Country:US
Mailing Address - Phone:208-356-6772
Mailing Address - Fax:
Practice Address - Street 1:105 W MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2634
Practice Address - Country:US
Practice Address - Phone:208-356-6772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-24
Last Update Date:2009-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1037111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID16711661OtherMEDICARE GROUP PTAN
ID806710900Medicaid
ID16753471OtherMEDICARE PTAN