Provider Demographics
NPI:1407392178
Name:GRISAFFI, ADDISON (DC)
Entity Type:Individual
Prefix:
First Name:ADDISON
Middle Name:
Last Name:GRISAFFI
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 1:335 E LEWIS ST
Mailing Address - Street 2:STE 10
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-775-7123
Mailing Address - Fax:208-550-3348
Practice Address - Street 1:335 E LEWIS ST
Practice Address - Street 2:STE 10
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-775-7123
Practice Address - Fax:208-550-3348
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor