Provider Demographics
NPI:1861555286
Name:BACK COUNTRY CHIROPRACTIC AND WELLNESS CENTER INC.
Entity type:Organization
Organization Name:BACK COUNTRY CHIROPRACTIC AND WELLNESS CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MULNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-634-8129
Mailing Address - Street 1:201 PARK STREET
Mailing Address - Street 2:PO BOX 1005
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:208-634-7651
Practice Address - Street 1:201 PARK ST.
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-1005
Practice Address - Country:US
Practice Address - Phone:208-634-8129
Practice Address - Fax:208-634-7651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA595111NI0900X
IDCHIA578111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111NI0900XChiropractic ProvidersChiropractorInternistGroup - Multi-Specialty
Not Answered111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC9446OtherBLUE CROSS, UMA MULNICK
IDCHIA578OtherIRWIN MULNICK LICENSE #
IDCHIA595OtherUMA MULNICK, LICENSE #
IDC5782OtherBLUE CROSS IRWIN MULNICK
IDT67941Medicare UPIN
ID1672404Medicare ID - Type UnspecifiedIRWIN MULNICK, DC
IDT98155Medicare UPIN
ID1672431Medicare ID - Type UnspecifiedUMA MULNICK