Healthcare Provider Details

I. General information

NPI: 1730801812
Provider Name (Legal Business Name): OLANA RAE POOL CSFA, CSA, CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

305 E JEFFERSON ST
BOISE ID
83712-6231
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-9590
  • Fax: 208-381-9599
Mailing address:
  • Phone: 208-381-9590
  • Fax: 208-381-9599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: