Healthcare Provider Details

I. General information

NPI: 1013064690
Provider Name (Legal Business Name): IDAHO KIDNEY INSTITUTE LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4511 ZEBE AVE
CHUBBUCK ID
83202-4707
US

IV. Provider business mailing address

PO BOX 268934
OKLAHOMA CITY OK
73126-8934
US

V. Phone/Fax

Practice location:
  • Phone: 208-904-4780
  • Fax: 208-904-4832
Mailing address:
  • Phone: 208-904-4780
  • Fax: 208-904-4832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: FAHIM RAHIM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 208-904-4780