Provider Demographics
NPI:1992791982
Name:SANDELL, JOHN R (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:SANDELL
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 1:325 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2204
Mailing Address - Country:US
Mailing Address - Phone:208-882-8534
Mailing Address - Fax:208-882-6866
Practice Address - Street 1:325 W 3RD ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2204
Practice Address - Country:US
Practice Address - Phone:208-882-8534
Practice Address - Fax:208-882-6866
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-357111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT44438Medicare UPIN
ID1671001Medicare ID - Type Unspecified