Healthcare Provider Details

I. General information

NPI: 1720561103
Provider Name (Legal Business Name): PEARL PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 17TH ST STE B
AMMON ID
83406-6601
US

IV. Provider business mailing address

2705 E 17TH ST STE B
AMMON ID
83406-6601
US

V. Phone/Fax

Practice location:
  • Phone: 208-497-0566
  • Fax: 208-346-7501
Mailing address:
  • Phone: 208-497-0566
  • Fax: 208-346-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ZAKERY WARREN
Title or Position: OWNER/DIRECTOR
Credential: LCPC
Phone: 208-346-7500