Provider Demographics
NPI:1356409445
Name:LILJENQUIST, CODY SHAWN (DC)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:SHAWN
Last Name:LILJENQUIST
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 1:1700 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2436
Mailing Address - Country:US
Mailing Address - Phone:208-678-2631
Mailing Address - Fax:208-678-2631
Practice Address - Street 1:1700 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2436
Practice Address - Country:US
Practice Address - Phone:208-678-2631
Practice Address - Fax:208-678-2631
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA577111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002663000Medicaid
ID1672385Medicare ID - Type Unspecified
IDT92342Medicare UPIN