1891880779 NPI number — GRAND TETON CHIROPRACTIC, PLLC

Table of content: (NPI 1891880779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891880779 NPI number — GRAND TETON CHIROPRACTIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND TETON CHIROPRACTIC, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891880779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4317 AMBER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMMON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83406-4640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-529-1919
Provider Business Mailing Address Fax Number:
208-552-9447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1387 CAMBRIDGE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83401-4257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-1919
Provider Business Practice Location Address Fax Number:
208-552-9447
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
CRIDDLE
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
208-529-1919

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CHIA 904 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com