Provider Demographics
NPI:1700106663
Name:THE OTHER ROAD INCORPORATED
Entity Type:Organization
Organization Name:THE OTHER ROAD INCORPORATED
Other - Org Name:EVERGREEN CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HALES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-895-8595
Mailing Address - Street 1:1640 W CHERRY LN # 130
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8187
Mailing Address - Country:US
Mailing Address - Phone:208-895-8595
Mailing Address - Fax:208-895-8594
Practice Address - Street 1:1640 W CHERRY LN # 130
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8187
Practice Address - Country:US
Practice Address - Phone:208-895-8595
Practice Address - Fax:208-895-8594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8M574OtherBLUC CROSS GROUP#
ID8M574OtherBLUC CROSS GROUP#