Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | CHI-491 | ID |
N | 111NS0005X | Chiropractic Sports Physician | CHI-491 | ID |
NPI | 1225230972 |
---|---|
Provider Name | Dr. Kevin G Hearon |
First Address | Boise, ID 83704-4506 |
Second Address | Boise, ID 83704-4403 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C-4918 | (02) | ID |
T-02529 | (02) | ID |