Provider Demographics
NPI:1174001143
Name:IRIZARRY, EDGARDO JOSE (DC)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:JOSE
Last Name:IRIZARRY
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 1:5170 W RIVER SPRING DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-412-0208
Mailing Address - Fax:
Practice Address - Street 1:2416 CLEVELAND BLVD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4434
Practice Address - Country:US
Practice Address - Phone:208-412-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1642111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor