Provider Demographics
NPI:1811295447
Name:LILJENQUIST CHIROPRACTIC, P.A.
Entity type:Organization
Organization Name:LILJENQUIST CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:S
Authorized Official - Last Name:LILJENQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-678-2631
Mailing Address - Street 1:1700 OVERLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318
Mailing Address - Country:US
Mailing Address - Phone:208-678-2631
Mailing Address - Fax:208-678-3334
Practice Address - Street 1:1700 OVERLAND AVENUE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318
Practice Address - Country:US
Practice Address - Phone:208-678-2631
Practice Address - Fax:208-678-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACC-78171100000X
IDCH1A577111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002663000Medicaid
ID1672385Medicare UPIN