Provider Demographics
NPI:1023166436
Name:SERMON, FREDDIE L (DC)
Entity type:Individual
Prefix:DR
First Name:FREDDIE
Middle Name:L
Last Name:SERMON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:FREDDIE
Other - Middle Name:L
Other - Last Name:SERMON
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:777 HOOPES AVE K306
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6093
Mailing Address - Country:US
Mailing Address - Phone:208-206-0237
Mailing Address - Fax:
Practice Address - Street 1:1880E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6468
Practice Address - Country:US
Practice Address - Phone:208-206-0237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCH-679111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1672925Medicare ID - Type Unspecified
IDU-39224Medicare UPIN
IDU-39224Medicare UPIN