Provider Demographics
NPI:1881131886
Name:COL323 PLLC
Entity type:Organization
Organization Name:COL323 PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:VICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-772-5047
Mailing Address - Street 1:8475 N GOVERNMENT WAY
Mailing Address - Street 2:103
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8670
Mailing Address - Country:US
Mailing Address - Phone:208-722-5047
Mailing Address - Fax:
Practice Address - Street 1:8475 N GOVERNMENT WAY
Practice Address - Street 2:103
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8670
Practice Address - Country:US
Practice Address - Phone:208-722-5047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty