Provider Demographics
NPI:1225220148
Name:SPINE ALIGN CHIROPRACTIC INC
Entity Type:Organization
Organization Name:SPINE ALIGN CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:L
Authorized Official - Last Name:REESE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-227-0400
Mailing Address - Street 1:1491 CURLEW DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4764
Mailing Address - Country:US
Mailing Address - Phone:208-227-0400
Mailing Address - Fax:208-227-0401
Practice Address - Street 1:1491 CURLEW DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4764
Practice Address - Country:US
Practice Address - Phone:208-227-0400
Practice Address - Fax:208-227-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU94140Medicare UPIN
ID1675165Medicare PIN