Healthcare Provider Details

I. General information

NPI: 1982922043
Provider Name (Legal Business Name): PRACTICE PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4185 BIRCHWOOD CIR
AMMON ID
83406-4648
US

IV. Provider business mailing address

4185 BIRCHWOOD CIR
AMMON ID
83406-4648
US

V. Phone/Fax

Practice location:
  • Phone: 208-528-8599
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT-965
License Number StateID

VIII. Authorized Official

Name: MRS. TOMI NICHOLE SMITH
Title or Position: PRESIDENT
Credential:
Phone: 208-528-8599