Healthcare Provider Details

I. General information

NPI: 1255985321
Provider Name (Legal Business Name): CDE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2019
Last Update Date: 07/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13150 W PERSIMMON LN
BOISE ID
83713-1986
US

IV. Provider business mailing address

13150 W PERSIMMON LN
BOISE ID
83713-1986
US

V. Phone/Fax

Practice location:
  • Phone: 208-965-0905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NATALIE DOMANGUE-SHIFLETT
Title or Position: DIRECTOR
Credential: MD
Phone: 208-965-0905