Provider Demographics
NPI:1689709735
Name:DR. MICK L. TIEGS, INC., PS
Entity Type:Organization
Organization Name:DR. MICK L. TIEGS, INC., PS
Other - Org Name:NORTHSIDE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:MICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:TIEGS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-571-8418
Mailing Address - Street 1:2301 N 36TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5207
Mailing Address - Country:US
Mailing Address - Phone:208-571-8418
Mailing Address - Fax:208-344-5277
Practice Address - Street 1:2301 N 36TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5207
Practice Address - Country:US
Practice Address - Phone:208-571-8418
Practice Address - Fax:208-344-5277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3119111N00000X
IDCHIA-1056261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1497750350OtherNPI-INDIVIDUAL
WA1497750350OtherNPI-INDIVIDUAL