Healthcare Provider Details

I. General information

NPI: 1710269832
Provider Name (Legal Business Name): TERESA BERNADETTE KOBZA RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W STATE ST
BOISE ID
83702
US

IV. Provider business mailing address

450 W STATE ST
BOISE ID
83702-6056
US

V. Phone/Fax

Practice location:
  • Phone: 208-334-5952
  • Fax:
Mailing address:
  • Phone: 208-334-5952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-646
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: