Provider Demographics
NPI:1700364437
Name:OPTIMAL HEALTH VENTURES LLC DBA BOISE INTEGRATED CHIROPRACTIC
Entity Type:Organization
Organization Name:OPTIMAL HEALTH VENTURES LLC DBA BOISE INTEGRATED CHIROPRACTIC
Other - Org Name:BOISE INTEGRATED CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER - PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NOAH
Authorized Official - Middle Name:B
Authorized Official - Last Name:EDVALSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-629-5374
Mailing Address - Street 1:3271 N MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4425
Mailing Address - Country:US
Mailing Address - Phone:208-629-5374
Mailing Address - Fax:
Practice Address - Street 1:3224 N MAPLE GROVE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4214
Practice Address - Country:US
Practice Address - Phone:208-629-5374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOISE INTEGRATED CHIROPRACTIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-03
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1368111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty