Provider Demographics
NPI:1619597895
Name:ANDROSOV, MELISSA (DC)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:ANDROSOV
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NORTHWEST BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2413
Mailing Address - Country:US
Mailing Address - Phone:208-610-3779
Mailing Address - Fax:
Practice Address - Street 1:1500 NORTHWEST BLVD # I
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2479
Practice Address - Country:US
Practice Address - Phone:208-610-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1990111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor