Provider Demographics
NPI:1114124138
Name:BOISE SPORTS CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:BOISE SPORTS CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEARON
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:208-377-9930
Mailing Address - Street 1:3314 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3314 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4403
Practice Address - Country:US
Practice Address - Phone:208-377-9930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC-4918111N00000X, 111NN1001X, 111NR0400X, 111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Not Answered111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Not Answered111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC-4918OtherIDAHO LICENSE NO.
IDC-4918OtherIDAHO LICENSE NO.