Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | CHIA0610 | ID |
NPI | 1003084989 |
---|---|
Provider Name | Johnnie R Clemans |
First Address | Boise, ID 83704-5849 |
Second Address | Boise, ID 83704-5849 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/02/2008 |
Last Update Date | 13/02/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U20591 | (02) | ID |