| Organization Name: | GRAND TETON CHIROPRACTIC, PLLC |
| NPI Number: | 1891880779 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JAMES CRIDDLE GARDNER (OWNER/MANAGER) |
| Mailing Address: | 1387 Cambridge Dr Suite 100 Idaho Falls |
| State: | ID US |
| Postal Code: | 834014257 |
| Phone Number: | 2085291919 |
| Fax Number: | 2085529447 |
| NPI Enumeration Date: | 10/04/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | CHIA 904 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |