Provider Demographics
NPI:1871761148
Name:CLEARWATER CHIROPRACTIC & ACUPUNCTURE PA
Entity type:Organization
Organization Name:CLEARWATER CHIROPRACTIC & ACUPUNCTURE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:AUBUCHON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, DC
Authorized Official - Phone:208-798-5420
Mailing Address - Street 1:25040 BURROW LN
Mailing Address - Street 2:
Mailing Address - City:JULIAETTA
Mailing Address - State:ID
Mailing Address - Zip Code:83535-5004
Mailing Address - Country:US
Mailing Address - Phone:208-305-5547
Mailing Address - Fax:208-836-5755
Practice Address - Street 1:25040 BURROW LN
Practice Address - Street 2:
Practice Address - City:JULIAETTA
Practice Address - State:ID
Practice Address - Zip Code:83535-5004
Practice Address - Country:US
Practice Address - Phone:208-305-5547
Practice Address - Fax:208-836-5755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2025-01-29
Deactivation Date:2025-01-17
Deactivation Code:
Reactivation Date:2025-01-22
Provider Licenses
StateLicense IDTaxonomies
IDCHIA826111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAC8901OtherBLUE CROSS OF IDAHO
ID1674346Medicare PIN
GAC8901OtherBLUE CROSS OF IDAHO