Provider Demographics
NPI:1942497532
Name:MOLDENHAUER CHIROPRACTIC CENTER PC
Entity Type:Organization
Organization Name:MOLDENHAUER CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOLDENHAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-467-5759
Mailing Address - Street 1:228 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5104
Mailing Address - Country:US
Mailing Address - Phone:208-467-5759
Mailing Address - Fax:208-467-4510
Practice Address - Street 1:228 HOLLY ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5104
Practice Address - Country:US
Practice Address - Phone:208-467-5759
Practice Address - Fax:208-467-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA296111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCK7825OtherMEDICARE RAILROAD
ID002554100Medicaid
IDC9420OtherBLUE CROSS
ID000010008275OtherBLUE SHIELD
ID1675137Medicare PIN