Healthcare Provider Details

I. General information

NPI: 1700621661
Provider Name (Legal Business Name): HIGH DESERT WOUND CARE AND HYPERBARICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 FAIRVIEW AVE STE 130
CALDWELL ID
83605-5433
US

IV. Provider business mailing address

PO BOX 45060
BOISE ID
83711-5060
US

V. Phone/Fax

Practice location:
  • Phone: 208-649-8347
  • Fax:
Mailing address:
  • Phone: 208-649-8347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMI YANTIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-649-8347