Healthcare Provider Details

I. General information

NPI: 1902924723
Provider Name (Legal Business Name): KIP ANDREW DRIBNAK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 W MALLARD DR STE A
BOISE ID
83706-3995
US

IV. Provider business mailing address

4207 E WISTERIA AVE
NAMPA ID
83687-8774
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-9826
  • Fax:
Mailing address:
  • Phone: 208-461-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-204
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: