Provider Demographics
NPI:1255408399
Name:SQUIRE, GEORGE CHESTER (DC)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:CHESTER
Last Name:SQUIRE
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 1:111 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5705
Mailing Address - Country:US
Mailing Address - Phone:208-585-3657
Mailing Address - Fax:208-585-3658
Practice Address - Street 1:111 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-5705
Practice Address - Country:US
Practice Address - Phone:208-585-3657
Practice Address - Fax:208-585-3658
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA396111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1674846Medicare ID - Type UnspecifiedGROUP
IDT44446Medicare UPIN