Provider Demographics
NPI:1790810380
Name:MAIN, JONATHAN ERIC (DC)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ERIC
Last Name:MAIN
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 1:2300 W EVEREST LN
Mailing Address - Street 2:SUITE #175
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5925
Mailing Address - Country:US
Mailing Address - Phone:208-895-0858
Mailing Address - Fax:208-895-0561
Practice Address - Street 1:2300 W EVEREST LN
Practice Address - Street 2:SUITE #175
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5925
Practice Address - Country:US
Practice Address - Phone:208-895-0858
Practice Address - Fax:208-895-0561
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-991111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC3167OtherBLUE CROSS BLUE SHIELD
ID1675474Medicare UPIN
ID1675474Medicare PIN