Provider Demographics
NPI:1992838601
Name:BOOTH, DAVID GEORGE (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GEORGE
Last Name:BOOTH
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 1:645 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5596
Mailing Address - Country:US
Mailing Address - Phone:208-552-9886
Mailing Address - Fax:208-552-9843
Practice Address - Street 1:60 S 2ND W
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1819
Practice Address - Country:US
Practice Address - Phone:208-359-2264
Practice Address - Fax:208-359-0650
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA804111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC8042OtherBLUE CROSS NUMBER
ID805108000Medicaid