Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | CHIA-1963 | ID |
N | 111NR0400X | Rehabilitation Chiropractor | CHIA-1963 | ID |
NPI | 1356992788 |
---|---|
Provider Name | Dr. John Robert Bynum |
First Address | Boise, ID 83709-3078 |
Second Address | Boise, ID 83709-3078 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2019 |
Last Update Date | 26/09/2019 |