Provider Demographics
NPI:1639280712
Name:IDAHO CHIROPRACTIC GROUP, PLLC
Entity type:Organization
Organization Name:IDAHO CHIROPRACTIC GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAREAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-343-6900
Mailing Address - Street 1:PO BOX 7442
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-1442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:403 S 11TH ST
Practice Address - Street 2:SUITE #110
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6968
Practice Address - Country:US
Practice Address - Phone:208-343-6900
Practice Address - Fax:208-343-0642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-802111N00000X
IDCHIA-559111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC1526OtherBLUE CROSS
ID000010027629OtherBLUE SHIELD
IDC1526OtherBLUE CROSS