Provider Demographics
NPI:1598820128
Name:GENTRY, ROBERT E (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
Last Name:GENTRY
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 1:1565 E LEIGHFIELD DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646
Mailing Address - Country:US
Mailing Address - Phone:208-008-2142
Mailing Address - Fax:
Practice Address - Street 1:1565 E LEIGHFIELD DR
Practice Address - Street 2:SUITE 150
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646
Practice Address - Country:US
Practice Address - Phone:208-884-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA 692 ID111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID42664Medicare UPIN