Healthcare Provider Details

I. General information

NPI: 1821303504
Provider Name (Legal Business Name): NATIONWIDE NEURO HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 08/18/2010
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 Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: WADE S HARRIS
Title or Position: OWNER
Credential: MD
Phone: 208-454-0567