Provider Demographics
NPI:1164610796
Name:SPINAL DYNAMICS CHIROPRACTIC AND REHABILITATION SPECIALISTS, INC.
Entity Type:Organization
Organization Name:SPINAL DYNAMICS CHIROPRACTIC AND REHABILITATION SPECIALISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-888-0055
Mailing Address - Street 1:3715 E OVERLAND RD
Mailing Address - Street 2:SUITE #105
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8395
Mailing Address - Country:US
Mailing Address - Phone:208-888-0055
Mailing Address - Fax:208-888-5062
Practice Address - Street 1:3715 E OVERLAND RD
Practice Address - Street 2:SUITE #105
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8395
Practice Address - Country:US
Practice Address - Phone:208-888-0055
Practice Address - Fax:208-888-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV102054-NVOtherMEDICARE ID
NV102054-NVOtherMEDICARE ID