MEDICARE: CALVIN WOODROW UDALL BS QIDP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator		ID

General Provider Information

NPI Number	:	1982538047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALVIN WOODROW UDALL BS QIDP

Provider Business Mailing Address
First Line	:	1349 W MARTIN ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-4166
Country	:	US
Telephone Number	:	208-422-4891
Fax Number	:

Provider Business Practice Location Address
First Line	:	1349 W MARTIN ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-4166
Country	:	US
Telephone Number	:	208-422-4891
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2026
Last Update Date	:	06/15/2026

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