Healthcare Provider Details

I. General information

NPI: 1811295447
Provider Name (Legal Business Name): LILJENQUIST CHIROPRACTIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2011
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 OVERLAND AVENUE
BURLEY ID
83318
US

IV. Provider business mailing address

1700 OVERLAND AVENUE
BURLEY ID
83318
US

V. Phone/Fax

Practice location:
  • Phone: 208-678-2631
  • Fax: 208-678-3334
Mailing address:
  • Phone: 208-678-2631
  • Fax: 208-678-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH1A577
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberACC-78
License Number StateID

VIII. Authorized Official

Name: CODY S. LILJENQUIST
Title or Position: OWNER/CHIROPRACTOR
Credential: D.C.
Phone: 208-678-2631