Provider Demographics
NPI:1245408657
Name:ANDERSON, JOHN R (DC,)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:ANDERSON
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 1:135 S WAKEA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-1385
Mailing Address - Country:US
Mailing Address - Phone:808-495-5767
Mailing Address - Fax:808-377-4377
Practice Address - Street 1:135 S WAKEA AVE STE 102
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1385
Practice Address - Country:US
Practice Address - Phone:808-495-5767
Practice Address - Fax:808-377-4377
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI786111N00000X
NVB-442111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVU49489Medicare UPIN