Provider Demographics
NPI:1861682353
Name:HARDISON-WALZ PC
Entity Type:Organization
Organization Name:HARDISON-WALZ PC
Other - Org Name:MOUNTAIN VIEW CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARDISON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-777-0128
Mailing Address - Street 1:1624 E SELTICE WAY
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:208-777-0128
Mailing Address - Fax:208-773-9600
Practice Address - Street 1:1624 E SELTICE WAY
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7022
Practice Address - Country:US
Practice Address - Phone:208-777-0128
Practice Address - Fax:208-773-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA964111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010156505OtherREGENCE BLUE SHIELD
IDC2532OtherBLUE CROSS OF IDAHO
ID807387600Medicaid
ID807387600Medicaid
ID000010156505OtherREGENCE BLUE SHIELD