Provider Demographics
NPI:1568534733
Name:ANGUIANO, OMAR (DC)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:ANGUIANO
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 1:3085 E MAGIC VIEW DR. SUITE 180
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-888-6077
Mailing Address - Fax:888-447-1415
Practice Address - Street 1:3085 E MAGIC VIEW DR. SUITE 180
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-888-6077
Practice Address - Fax:888-447-1415
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29440111N00000X
IDCHIA-1820111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV03072Medicare UPIN