Provider Demographics
NPI:1053558973
Name:STOCKWELL, MANFRED ROSS (DC)
Entity type:Individual
Prefix:DR
First Name:MANFRED
Middle Name:ROSS
Last Name:STOCKWELL
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 1:5027 CREE WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5344
Mailing Address - Country:US
Mailing Address - Phone:208-362-6530
Mailing Address - Fax:208-362-6530
Practice Address - Street 1:5027 CREE WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-5344
Practice Address - Country:US
Practice Address - Phone:208-362-6530
Practice Address - Fax:208-362-6530
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010031901OtherREGENCE B/C
IDC-7291OtherBLUE CROSS