Healthcare Provider Details

I. General information

NPI: 1861064206
Provider Name (Legal Business Name): CLAUDIA JAE BERMENSOLO RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 S MANITOU AVE
BOISE ID
83706-4150
US

IV. Provider business mailing address

2101 S MANITOU AVE
BOISE ID
83706-4150
US

V. Phone/Fax

Practice location:
  • Phone: 208-591-0005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberLRT-2228
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: