Provider Demographics
NPI:1740281435
Name:BURKE FAMILY CHIROPRACTIC INTEGRATIVE HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:BURKE FAMILY CHIROPRACTIC INTEGRATIVE HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-542-6564
Mailing Address - Street 1:1348 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6270
Mailing Address - Country:US
Mailing Address - Phone:208-542-6564
Mailing Address - Fax:208-542-6571
Practice Address - Street 1:1348 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6270
Practice Address - Country:US
Practice Address - Phone:208-542-6564
Practice Address - Fax:208-542-6571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-792111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805243000Medicaid
ID805243000Medicaid