Provider Demographics
NPI:1114571726
Name:CROFT, SAMUEL WADE (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:WADE
Last Name:CROFT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 N 3800 E
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5457
Mailing Address - Country:US
Mailing Address - Phone:208-821-2825
Mailing Address - Fax:
Practice Address - Street 1:661 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5596
Practice Address - Country:US
Practice Address - Phone:208-569-9450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-2241111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor