Provider Demographics
NPI:1144208281
Name:WHALEN, JOHN E (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:WHALEN
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 1:1326 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1703
Mailing Address - Country:US
Mailing Address - Phone:208-884-3368
Mailing Address - Fax:208-884-3394
Practice Address - Street 1:1326 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1703
Practice Address - Country:US
Practice Address - Phone:208-884-3368
Practice Address - Fax:208-884-3394
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-655111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010021800OtherBLUE SHIELD
IDC6558OtherBLUE CROSS
IDCHIA655OtherLICENSE
IDC6558OtherBLUE CROSS
ID1672697Medicare ID - Type Unspecified
ID820512942OtherTIN