Provider Demographics
NPI:1609479419
Name:BOSTROM, THOR STEPHEN (DC)
Entity Type:Individual
Prefix:DR
First Name:THOR
Middle Name:STEPHEN
Last Name:BOSTROM
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 1:4156 N PLAYER DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-1603
Mailing Address - Country:US
Mailing Address - Phone:425-417-8566
Mailing Address - Fax:
Practice Address - Street 1:810 E SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4149
Practice Address - Country:US
Practice Address - Phone:208-665-2293
Practice Address - Fax:208-908-6038
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTCHI-CHI-LIC-6726111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor