Provider Demographics
NPI:1861575961
Name:MAYO, PATRICK TERRY (DC)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:TERRY
Last Name:MAYO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3298 E 17TH STREET
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406
Mailing Address - Country:US
Mailing Address - Phone:208-522-3863
Mailing Address - Fax:208-522-3863
Practice Address - Street 1:3298 E 17TH STREET
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406
Practice Address - Country:US
Practice Address - Phone:208-522-3863
Practice Address - Fax:208-522-3863
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA434111N00000X
IDACC79171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010008923OtherREGENCE BLUE SHIELD
C4348OtherBLUE CROSS
000010008923OtherREGENCE BLUE SHIELD
T44489Medicare UPIN