Provider Demographics
NPI:1750420576
Name:OLYMPUS FAMILY WELLNESS CENTER, P.C.
Entity type:Organization
Organization Name:OLYMPUS FAMILY WELLNESS CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:E
Authorized Official - Last Name:YOUNGBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-232-0200
Mailing Address - Street 1:1598 DELPHIC WAY
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2285
Mailing Address - Country:US
Mailing Address - Phone:208-232-0220
Mailing Address - Fax:208-237-9569
Practice Address - Street 1:1598 DELPHIC WAY
Practice Address - Street 2:SUITE A-2
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2285
Practice Address - Country:US
Practice Address - Phone:208-232-0220
Practice Address - Fax:208-237-9569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376980Medicare PIN