Provider Demographics
NPI:1265677587
Name:LINDSTROM, CORY SHANE (DC)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:SHANE
Last Name:LINDSTROM
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 1:5216 E. CLEVELAND BLVD.
Mailing Address - Street 2:STE G
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607
Mailing Address - Country:US
Mailing Address - Phone:208-454-5500
Mailing Address - Fax:208-454-8877
Practice Address - Street 1:5216 E. CLEVELAND BLVD
Practice Address - Street 2:STE G
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607
Practice Address - Country:US
Practice Address - Phone:208-454-5500
Practice Address - Fax:208-454-8877
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1335111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808502300Medicaid
ID167Medicare PIN
ID808502300Medicaid