Provider Demographics
NPI:1457429441
Name:LILJENQUIST, DANA F (DC)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:F
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 1:1605 N ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-2504
Mailing Address - Country:US
Mailing Address - Phone:208-233-4700
Mailing Address - Fax:208-233-4701
Practice Address - Street 1:1605 N ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-2504
Practice Address - Country:US
Practice Address - Phone:208-233-4700
Practice Address - Fax:208-233-4701
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-409111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT44452Medicare UPIN
ID1671212Medicare ID - Type UnspecifiedMEDICARE