Provider Demographics
NPI:1053193722
Name:BROWN, DESIRAE I (DC)
Entity type:Individual
Prefix:
First Name:DESIRAE
Middle Name:I
Last Name:BROWN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6452 N AGRARIAN LN APT B
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1487
Mailing Address - Country:US
Mailing Address - Phone:208-614-8090
Mailing Address - Fax:
Practice Address - Street 1:5402 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2640
Practice Address - Country:US
Practice Address - Phone:208-614-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2023-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-2367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty