Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | CHIA-1675 | ID |
N | 111NR0400X | Rehabilitation Chiropractor | CHIA-1675 | ID |
NPI | 1245694041 |
---|---|
Provider Name | Justin Michael Anderson |
First Address | Boise, ID 83714-1926 |
Second Address | Boise, ID 83714-1926 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/04/2016 |
Last Update Date | 07/02/2021 |