Provider Demographics
NPI:1184077646
Name:MCCROCKLIN, MINDY (DC)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:MCCROCKLIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2128 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7311
Mailing Address - Country:US
Mailing Address - Phone:208-249-9629
Mailing Address - Fax:
Practice Address - Street 1:2128 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7311
Practice Address - Country:US
Practice Address - Phone:208-249-9629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1621111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDMCDMedicaid