Provider Demographics
NPI:1235641374
Name:FLACK, RAYMOND DREW
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:DREW
Last Name:FLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 E OVERLAND RD STE 110
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5111
Mailing Address - Country:US
Mailing Address - Phone:208-888-4646
Mailing Address - Fax:
Practice Address - Street 1:3405 E OVERLAND RD STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5111
Practice Address - Country:US
Practice Address - Phone:208-888-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1802111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor