Provider Demographics
NPI:1114975612
Name:THIRY, JOHN LEO (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEO
Last Name:THIRY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381 W PARKCENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3654
Mailing Address - Country:US
Mailing Address - Phone:208-344-0000
Mailing Address - Fax:208-344-8377
Practice Address - Street 1:381 W PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3654
Practice Address - Country:US
Practice Address - Phone:208-344-0000
Practice Address - Fax:208-344-8377
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC528111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT-44507Medicare UPIN
ID1672019Medicare ID - Type Unspecified