Provider Demographics
NPI:1467897405
Name:DUDLEY CHIROPRACTIC P.A.
Entity Type:Organization
Organization Name:DUDLEY CHIROPRACTIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:BALLARD
Authorized Official - Last Name:WEED
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-266-7000
Mailing Address - Street 1:13965 W CHINDEN BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1457
Mailing Address - Country:US
Mailing Address - Phone:208-266-7000
Mailing Address - Fax:208-417-1888
Practice Address - Street 1:13965 W CHINDEN BLVD STE 210
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1457
Practice Address - Country:US
Practice Address - Phone:208-344-3610
Practice Address - Fax:208-417-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-03
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-868111N00000X
111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808566100Medicaid