Healthcare Provider Details

I. General information

NPI: 1679023790
Provider Name (Legal Business Name): ANDREW KYLE DAVID SCHEETS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

2808 W KOOTENAI ST
BOISE ID
83705-2323
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-2900
  • Fax:
Mailing address:
  • Phone: 208-871-6948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberID000062300605
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: