Healthcare Provider Details

I. General information

NPI: 1437178399
Provider Name (Legal Business Name): IDAHO FACIAL IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8119 USTICK RD SUITE 101
BOISE ID
83704-5754
US

IV. Provider business mailing address

8119 USTICK RD SUITE 101
BOISE ID
83704-5754
US

V. Phone/Fax

Practice location:
  • Phone: 208-514-4740
  • Fax: 208-376-7012
Mailing address:
  • Phone: 208-514-4740
  • Fax: 208-376-7012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number4-D-2095
License Number StateID

VIII. Authorized Official

Name: DR. BRADEN M STAUTS
Title or Position: OWNER/PARTNER
Credential: DDS
Phone: 208-514-4740