Healthcare Provider Details

I. General information

NPI: 1629358445
Provider Name (Legal Business Name): MARK JAMES WEST BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N CLOVERDALE RD SUITE #213
BOISE ID
83713-1081
US

IV. Provider business mailing address

4700 N CLOVERDALE RD SUITE #213
BOISE ID
83713-1081
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-0109
  • Fax:
Mailing address:
  • Phone: 208-377-0109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA-269
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: