Provider Demographics
NPI:1881631208
Name:INTERMOUNTAIN CHIROPRACTIC
Entity Type:Organization
Organization Name:INTERMOUNTAIN CHIROPRACTIC
Other - Org Name:OLIVER CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER - PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:208-376-3111
Mailing Address - Street 1:5515 OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2728
Mailing Address - Country:US
Mailing Address - Phone:208-376-3111
Mailing Address - Fax:208-376-3175
Practice Address - Street 1:5515 OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2728
Practice Address - Country:US
Practice Address - Phone:208-376-3111
Practice Address - Fax:208-376-3175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCH1A632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1673045Medicare ID - Type Unspecified
U47410Medicare UPIN