Provider Demographics
NPI:1053544510
Name:5 MILE PLAZA CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:5 MILE PLAZA CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:MEISSNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-322-0051
Mailing Address - Street 1:10406 OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1433
Mailing Address - Country:US
Mailing Address - Phone:208-322-0051
Mailing Address - Fax:
Practice Address - Street 1:10406 OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1433
Practice Address - Country:US
Practice Address - Phone:208-322-0051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA4603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID111458OtherUNITED HEALTHCARE
IDT44479OtherUPIN
ID111458OtherUNITED HEALTHCARE