Provider Demographics
NPI:1386630531
Name:CLEVERLEY, JUSTIN RAY (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RAY
Last Name:CLEVERLEY
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 1:800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUHL
Mailing Address - State:ID
Mailing Address - Zip Code:83316-1236
Mailing Address - Country:US
Mailing Address - Phone:208-543-2005
Mailing Address - Fax:208-543-4172
Practice Address - Street 1:800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUHL
Practice Address - State:ID
Practice Address - Zip Code:83316-1236
Practice Address - Country:US
Practice Address - Phone:208-543-2005
Practice Address - Fax:208-543-4172
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-902111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC1575OtherBLUE CROSS
ID805752600Medicaid
ID000010027755OtherREGENCE BLUE SHIELD
IDU78642Medicare UPIN
ID805752600Medicaid
ID1674100Medicare UPIN