Provider Demographics
NPI:1437877321
Name:DR. MICHAEL D. RAE, DC, PLLC
Entity Type:Organization
Organization Name:DR. MICHAEL D. RAE, DC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-985-3233
Mailing Address - Street 1:1729 S GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3529
Mailing Address - Country:US
Mailing Address - Phone:208-985-3233
Mailing Address - Fax:
Practice Address - Street 1:1843 S BROADWAY AVE STE 203A
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3862
Practice Address - Country:US
Practice Address - Phone:208-985-3233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-17
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCHIA-1332OtherIDAHO STATE BOARD OF CHIROPRACTIC PHYSICIAN'S