Provider Demographics
NPI:1861725400
Name:KEYSTONE OF HEALTH CHIROPRACTIC
Entity type:Organization
Organization Name:KEYSTONE OF HEALTH CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-676-7984
Mailing Address - Street 1:10998 W BOX CANYON ST
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5691
Mailing Address - Country:US
Mailing Address - Phone:563-676-7984
Mailing Address - Fax:
Practice Address - Street 1:10998 W BOX CANYON ST
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5691
Practice Address - Country:US
Practice Address - Phone:563-676-7984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1376111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty