Healthcare Provider Details

I. General information

NPI: 1346715703
Provider Name (Legal Business Name): JESUS VARGAS ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N CURTIS RD STE 204
BOISE ID
83706-1340
US

IV. Provider business mailing address

3416 W MEADOW DR
BOISE ID
83706-2739
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-3315
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-662
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: