Provider Demographics
NPI:1992761928
Name:ANDERSON, CARL (DC)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
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 1:1505 S FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1374
Mailing Address - Country:US
Mailing Address - Phone:208-377-0577
Mailing Address - Fax:208-658-6085
Practice Address - Street 1:1505 S FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1374
Practice Address - Country:US
Practice Address - Phone:208-377-0577
Practice Address - Fax:208-658-6085
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-923111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV06781Medicare UPIN
ID1368538Medicare ID - Type Unspecified
ID1368538Medicare PIN