Provider Demographics
NPI:1982246336
Name:STIVISON, AUSTIN JOSHUA (DC)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JOSHUA
Last Name:STIVISON
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 1:9960 N BIZTOWN LOOP
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-5197
Mailing Address - Country:US
Mailing Address - Phone:208-762-3660
Mailing Address - Fax:208-762-3600
Practice Address - Street 1:9960 N BIZTOWN LOOP
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-5197
Practice Address - Country:US
Practice Address - Phone:208-762-3660
Practice Address - Fax:208-762-3600
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61004790111NR0400X
IDCHIA-2111111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation