1588921654 NPI number — ORCHARD CHIROPRACTIC, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588921654 NPI number — ORCHARD CHIROPRACTIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORCHARD CHIROPRACTIC, INC
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:
1588921654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 456
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REXBURG
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83440-0456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-656-8883
Provider Business Mailing Address Fax Number:
208-656-8883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 VALLEY RIVER DR STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440-5313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-656-8883
Provider Business Practice Location Address Fax Number:
208-656-8883
Provider Enumeration Date:
04/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ORCHARD
Authorized Official First Name:
TODD
Authorized Official Middle Name:
ALVIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-656-8883

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CHIA-1002 , 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)

  • Identifier: M8063862 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010159874 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: C9905 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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