Healthcare Provider Details

I. General information

NPI: 1003650250
Provider Name (Legal Business Name): JENNIFER LYNN RICE LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2024
Last Update Date: 06/22/2024
Certification Date: 06/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 W FAIRVIEW AVE
BOISE ID
83702-6722
US

IV. Provider business mailing address

3410 N WHISTLER LN APT 107
BOISE ID
83703-6903
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-2676
  • Fax:
Mailing address:
  • Phone: 208-404-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-911
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: