Provider Demographics
NPI:1780290981
Name:EAST RIDGE CHIROPRACTIC
Entity type:Organization
Organization Name:EAST RIDGE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-551-5365
Mailing Address - Street 1:1320 S AMMON RD
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-5810
Mailing Address - Country:US
Mailing Address - Phone:509-551-5365
Mailing Address - Fax:
Practice Address - Street 1:1320 S AMMON RD
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-5810
Practice Address - Country:US
Practice Address - Phone:509-551-5365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-22
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty