Individual
GRETCHEN MICHELLE BLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.C.
Contact information
Practice address
105 W MAIN ST, REXBURG, ID 83440-2634
(208) 356-6772
Mailing address
105 W MAIN ST, REXBURG, ID 83440-2634
(208) 356-6772
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
CHIA-1037
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
16711661
MEDICARE GROUP PTAN
ID
01
—
16753471
MEDICARE PTAN
ID
05
—
806710900
—
ID
Enumeration date
03/24/2007
Last updated
08/08/2009
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