Provider Demographics
NPI:1467535260
Name:WIRICK FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:WIRICK FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:WIRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-523-1620
Mailing Address - Street 1:1542 ELK CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-523-1620
Mailing Address - Fax:208-523-1497
Practice Address - Street 1:2238 ST. CLAIR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-523-1620
Practice Address - Fax:208-523-1497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1203111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1164524658OtherPROVIDER NPI