Provider Demographics
NPI:1710126552
Name:ALTERNATIVE MEDICINE AND DIAGNOSTICS
Entity type:Organization
Organization Name:ALTERNATIVE MEDICINE AND DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEVELLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-888-5951
Mailing Address - Street 1:5975 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-3012
Mailing Address - Country:US
Mailing Address - Phone:208-888-5951
Mailing Address - Fax:
Practice Address - Street 1:450 S MERIDIAN RD STE 95
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4537
Practice Address - Country:US
Practice Address - Phone:208-888-5951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA 1167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty