Provider Demographics
NPI:1942575477
Name:EASTGATE CHIROPRACTIC INCORPORATED
Entity Type:Organization
Organization Name:EASTGATE CHIROPRACTIC INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE-FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-743-0231
Mailing Address - Street 1:1132 BURRELL AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7101
Mailing Address - Country:US
Mailing Address - Phone:208-743-0231
Mailing Address - Fax:208-746-7462
Practice Address - Street 1:1132 BURRELL AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7101
Practice Address - Country:US
Practice Address - Phone:208-743-0231
Practice Address - Fax:208-746-7462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1051111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1675410Medicare UPIN