Provider Demographics
NPI:1215012554
Name:WIGHT, GARY CHRISTOPHER (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:CHRISTOPHER
Last Name:WIGHT
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 1:333 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4322
Mailing Address - Country:US
Mailing Address - Phone:208-522-2591
Mailing Address - Fax:208-524-7489
Practice Address - Street 1:203 N HOLMES AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2613
Practice Address - Country:US
Practice Address - Phone:208-522-2591
Practice Address - Fax:208-522-2591
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1163111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC5612OtherBLUE CROSS ID#
ID1670598Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
IDC5612OtherBLUE CROSS ID#