Provider Demographics
NPI:1174517858
Name:SAMPSON, RICHARD PAUL (RN,DC,FIAMA)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PAUL
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:RN,DC,FIAMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1707
Mailing Address - Country:US
Mailing Address - Phone:208-888-2267
Mailing Address - Fax:208-288-0260
Practice Address - Street 1:1504 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1707
Practice Address - Country:US
Practice Address - Phone:208-888-2267
Practice Address - Fax:208-288-0260
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA 470111N00000X
IDACC-57171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010007712OtherBLUE SHIELD
ID001618100Medicaid
IDC470-2OtherBLUE CROSS
ID1174517858Medicare NSC
ID000010007712OtherBLUE SHIELD
IDC470-2OtherBLUE CROSS