Healthcare Provider Details

I. General information

NPI: 1700088002
Provider Name (Legal Business Name): CHILDRENS KIDNEY SPECIALISTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST 200
BOISE ID
83712-6223
US

IV. Provider business mailing address

1935 NW NORFOLK CT
PORTLAND OR
97229-8448
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7336
  • Fax: 208-381-7495
Mailing address:
  • Phone: 503-297-3178
  • Fax: 208-381-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberM6943
License Number StateID

VIII. Authorized Official

Name: DR. RANDALL JENKINS
Title or Position: DOCTOR
Credential: MD
Phone: 208-381-7336