Provider Demographics
NPI:1720521719
Name:ADVANCED CHIROPRACTIC OF BLACKFOOT
Entity Type:Organization
Organization Name:ADVANCED CHIROPRACTIC OF BLACKFOOT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-0270
Mailing Address - Street 1:725 JENSEN GROVE DR
Mailing Address - Street 2:SUITE #4
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1636
Mailing Address - Country:US
Mailing Address - Phone:208-785-0270
Mailing Address - Fax:208-785-0683
Practice Address - Street 1:1395 NW MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-3936
Practice Address - Country:US
Practice Address - Phone:208-785-0270
Practice Address - Fax:208-785-0683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-23
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1502305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDZIR91475OtherTRADING PARTNER