Healthcare Provider Details

I. General information

NPI: 1932272127
Provider Name (Legal Business Name): ELIZABETH KENETTE ELLIN NBC-HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH KENETTE ELLIN NBC-HIS

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N MERIDIAN
BLACKFOOT ID
83221
US

IV. Provider business mailing address

4155 YELLOWSTONE AVE
POCATELLO ID
83202-2345
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-5551
  • Fax: 208-782-9580
Mailing address:
  • Phone: 208-238-0020
  • Fax: 208-238-0021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA-182
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: