Provider Demographics
NPI:1275849119
Name:PRESTON CHIROPRACTIC CLINIC, INC.
Entity Type:Organization
Organization Name:PRESTON CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-852-0083
Mailing Address - Street 1:122 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1143
Mailing Address - Country:US
Mailing Address - Phone:208-852-0083
Mailing Address - Fax:208-852-0051
Practice Address - Street 1:122 N STATE ST
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1143
Practice Address - Country:US
Practice Address - Phone:208-852-0083
Practice Address - Fax:208-852-0051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010008535OtherBLUE SHIELD
IDC4876OtherBLUE CROSS
ID1671837Medicare PIN
IDT44492Medicare UPIN