Healthcare Provider Details

I. General information

NPI: 1063585305
Provider Name (Legal Business Name): IDAHO SLEEP AND NEUROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E LOGAN ST SUITE 105
CALDWELL ID
83605-4882
US

IV. Provider business mailing address

211 E LOGAN ST SUITE 105
CALDWELL ID
83605-4882
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-0567
  • Fax: 208-454-0965
Mailing address:
  • Phone: 208-454-0567
  • Fax: 208-454-0965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateID

VIII. Authorized Official

Name: LANCE HALE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 208-454-0567