Healthcare Provider Details

I. General information

NPI: 1609748854
Provider Name (Legal Business Name): KYREN TWEEDIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 10/24/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3160 E 17TH ST STE 164
AMMON ID
83406-6784
US

IV. Provider business mailing address

1500 E VENTURE WAY APT 9206
POCATELLO ID
83201-1209
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-1795
  • Fax:
Mailing address:
  • Phone: 208-716-8547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberI71317
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: