Healthcare Provider Details

I. General information

NPI: 1326263179
Provider Name (Legal Business Name): KIRA ANN SKROH ATC. ATL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 E HOMEDALE RD
CALDWELL ID
83607-1848
US

IV. Provider business mailing address

8634 W WALL DR
BOISE ID
83709-5873
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-9253
  • Fax:
Mailing address:
  • Phone: 208-761-0713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-249
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: