Provider Demographics
NPI:1215005277
Name:WESTOVER, GLEN L (DC)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:L
Last Name:WESTOVER
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 1:301 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:ID
Mailing Address - Zip Code:83850-9767
Mailing Address - Country:US
Mailing Address - Phone:208-682-2122
Mailing Address - Fax:208-682-2825
Practice Address - Street 1:301 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:ID
Practice Address - Zip Code:83850-9767
Practice Address - Country:US
Practice Address - Phone:208-682-2122
Practice Address - Fax:208-682-2825
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-347111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC3555OtherBLUE CROSS
ID000010139794OtherBLUE SHIELD
IDC3555OtherBLUE CROSS
IDT 44433Medicare UPIN