Provider Demographics
NPI:1649449125
Name:DR NEIL A MAVITY
Entity type:Organization
Organization Name:DR NEIL A MAVITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-245-5349
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-0303
Mailing Address - Country:US
Mailing Address - Phone:208-245-5349
Mailing Address - Fax:208-245-0153
Practice Address - Street 1:132 S 2ND ST
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-2209
Practice Address - Country:US
Practice Address - Phone:208-245-5349
Practice Address - Fax:208-245-0153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1375089Medicare PIN