Provider Demographics
NPI:1386652691
Name:BURTENSHAW, STEPHEN KYLE (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:KYLE
Last Name:BURTENSHAW
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 1:757 E WYTHE CREEK CT STE 102
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-5006
Mailing Address - Country:US
Mailing Address - Phone:208-922-4908
Mailing Address - Fax:208-922-4909
Practice Address - Street 1:757 E WYTHE CREEK CT STE 102
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-5006
Practice Address - Country:US
Practice Address - Phone:208-922-4908
Practice Address - Fax:208-922-4909
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1159111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807407200Medicaid