Healthcare Provider Details

I. General information

NPI: 1992570550
Provider Name (Legal Business Name): DRPENNER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2023
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 E PINE ST
CALDWELL ID
83605-4836
US

IV. Provider business mailing address

108 E PINE ST
CALDWELL ID
83605-4836
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-0858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: DEVON PENNER
Title or Position: CHIROPRACTOR
Credential: D.C
Phone: 986-837-7884