Provider Demographics
NPI:1447483516
Name:ONE LIFE CHIROPRACTIC
Entity type:Organization
Organization Name:ONE LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:GIB
Authorized Official - Last Name:HEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-459-6141
Mailing Address - Street 1:317 HAPPY DAY BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-8115
Mailing Address - Country:US
Mailing Address - Phone:208-459-6141
Mailing Address - Fax:
Practice Address - Street 1:317 HAPPY DAY BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-8115
Practice Address - Country:US
Practice Address - Phone:208-459-6141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1342111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808321800Medicaid