Provider Demographics
NPI:1861639221
Name:HAMMON, JUSTIN TYRELL (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:TYRELL
Last Name:HAMMON
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 1:2105 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8026
Mailing Address - Country:US
Mailing Address - Phone:208-528-6010
Mailing Address - Fax:208-528-6011
Practice Address - Street 1:2105 NIAGARA ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8026
Practice Address - Country:US
Practice Address - Phone:208-528-6010
Practice Address - Fax:208-528-6011
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1341111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor