Provider Demographics
NPI:1972780260
Name:CLEVERLEY CHIROPRACTIC
Entity Type:Organization
Organization Name:CLEVERLEY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEVERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-543-2005
Mailing Address - Street 1:800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUHL
Mailing Address - State:ID
Mailing Address - Zip Code:83316-1236
Mailing Address - Country:US
Mailing Address - Phone:208-543-2005
Mailing Address - Fax:208-543-4172
Practice Address - Street 1:720 US-30
Practice Address - Street 2:
Practice Address - City:BUHL
Practice Address - State:ID
Practice Address - Zip Code:83316
Practice Address - Country:US
Practice Address - Phone:208-543-2005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA902111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC9917OtherBLUE CROSS OF IDAHO
ID000010027755OtherREGENCE BLUE SHIELD
ID805752600Medicaid