Healthcare Provider Details

I. General information

NPI: 1316243371
Provider Name (Legal Business Name): TREASURE VALLEY COLON & RECTAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 N LIBERTY ST SUITE 201
BOISE ID
83704-8706
US

IV. Provider business mailing address

1072 N LIBERTY ST SUITE 201
BOISE ID
83704-8706
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-2273
  • Fax: 208-367-3059
Mailing address:
  • Phone: 208-377-2273
  • Fax: 208-367-3059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM11186
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberM11186
License Number StateID

VIII. Authorized Official

Name: DR. JOHNNY B GREEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 208-377-2273