Provider Demographics
NPI:1598238412
Name:GRISAFFI SPORTS CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:GRISAFFI SPORTS CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DC
Authorized Official - Prefix:MR
Authorized Official - First Name:ADDISON
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRISAFFI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-775-7123
Mailing Address - Street 1:335 E LEWIS ST STE 10
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6408
Mailing Address - Country:US
Mailing Address - Phone:208-775-7123
Mailing Address - Fax:208-550-3348
Practice Address - Street 1:335 E LEWIS ST STE 10
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6408
Practice Address - Country:US
Practice Address - Phone:208-775-7123
Practice Address - Fax:208-550-3256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-03
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty