Provider Demographics
NPI:1942705546
Name:MINI-CASSIA CHIROPRACTIC & SPORTS MEDICINE
Entity Type:Organization
Organization Name:MINI-CASSIA CHIROPRACTIC & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:W
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-260-0917
Mailing Address - Street 1:2200 MACS AVE
Mailing Address - Street 2:
Mailing Address - City:HEYBURN
Mailing Address - State:ID
Mailing Address - Zip Code:83336-9734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2434
Practice Address - Country:US
Practice Address - Phone:208-260-0917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1817111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty