Provider Demographics
NPI:1952713166
Name:OFISA, SHALOAM (DC, MS)
Entity Type:Individual
Prefix:
First Name:SHALOAM
Middle Name:
Last Name:OFISA
Suffix:
Gender:M
Credentials:DC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 FLANDRO DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4912
Mailing Address - Country:US
Mailing Address - Phone:208-242-3723
Mailing Address - Fax:208-904-1052
Practice Address - Street 1:1800 FLANDRO DR
Practice Address - Street 2:SUITE 130
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202
Practice Address - Country:US
Practice Address - Phone:208-221-2973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1952713166Medicaid