Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | CHIA577 | ID |
NPI | 1356409445 |
---|---|
Provider Name | Cody Shawn Liljenquist |
First Address | Burley, ID 83318-2436 |
Second Address | Burley, ID 83318-2436 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
002663000 | (05) | ID |
T92342 | (02) | ID |