Provider Demographics
NPI:1508910373
Name:CHIRO PLUS
Entity Type:Organization
Organization Name:CHIRO PLUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TRAVISS
Authorized Official - Suffix:
Authorized Official - Credentials:CH
Authorized Official - Phone:208-762-1414
Mailing Address - Street 1:PO BOX 2376
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-2376
Mailing Address - Country:US
Mailing Address - Phone:208-762-1414
Mailing Address - Fax:208-762-1433
Practice Address - Street 1:15 W HONEYSUCKLE AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-2376
Practice Address - Country:US
Practice Address - Phone:208-762-1414
Practice Address - Fax:208-762-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA709111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1673163Medicare ID - Type Unspecified