Provider Demographics
NPI:1679519193
Name:GRAND TETON CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:GRAND TETON CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-529-1919
Mailing Address - Street 1:4317 AMBER LN
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4640
Mailing Address - Country:US
Mailing Address - Phone:208-542-9567
Mailing Address - Fax:208-552-9447
Practice Address - Street 1:1220 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6147
Practice Address - Country:US
Practice Address - Phone:208-529-1919
Practice Address - Fax:208-552-9447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA 904111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty