Provider Demographics
NPI:1093009847
Name:JEROME CHIROPRACTIC CLINIC PLLC
Entity Type:Organization
Organization Name:JEROME CHIROPRACTIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:MCCLAIN
Authorized Official - Last Name:SACCOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-324-0222
Mailing Address - Street 1:PO BOX 632
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-0632
Mailing Address - Country:US
Mailing Address - Phone:208-324-0222
Mailing Address - Fax:208-324-0223
Practice Address - Street 1:213 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-2624
Practice Address - Country:US
Practice Address - Phone:208-324-0222
Practice Address - Fax:208-324-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-650261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service