Provider Demographics
NPI:1952065104
Name:BARTHOLOMA, GREGORY (DC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BARTHOLOMA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2893 W 2200 S
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:ID
Mailing Address - Zip Code:83210-1850
Mailing Address - Country:US
Mailing Address - Phone:208-221-5301
Mailing Address - Fax:
Practice Address - Street 1:219 IDAHO ST
Practice Address - Street 2:
Practice Address - City:AMERICAN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83211-1235
Practice Address - Country:US
Practice Address - Phone:208-705-9992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1998111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor