Provider Demographics
NPI:1467877811
Name:GRZESZKOWIAK, MADISON (DC)
Entity Type:Individual
Prefix:DR
First Name:MADISON
Middle Name:
Last Name:GRZESZKOWIAK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2937
Mailing Address - Country:US
Mailing Address - Phone:208-596-1105
Mailing Address - Fax:208-883-6559
Practice Address - Street 1:414 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2937
Practice Address - Country:US
Practice Address - Phone:208-596-1105
Practice Address - Fax:208-883-6559
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1577111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor