Provider Demographics
NPI:1982806212
Name:TOTAL WELLNESS CHIROPRACTIC AND HOLISTIC CARE LLC
Entity Type:Organization
Organization Name:TOTAL WELLNESS CHIROPRACTIC AND HOLISTIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LINDSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-452-7582
Mailing Address - Street 1:211 N WHITLEY DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2704
Mailing Address - Country:US
Mailing Address - Phone:208-452-7582
Mailing Address - Fax:
Practice Address - Street 1:211 N WHITLEY DR
Practice Address - Street 2:SUITE 4
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2704
Practice Address - Country:US
Practice Address - Phone:208-452-7582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1197111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C5638OtherBLUE CROSS
000010157423OtherBLUE SHIELD
ID807598100Medicaid
C5638OtherBLUE CROSS
ID807598100Medicaid
000010157423OtherBLUE SHIELD