Healthcare Provider Details

I. General information

NPI: 1942373766
Provider Name (Legal Business Name): MICKEY RAY WEIMER C.F.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 E. RIVERSIDE DR #234
EAGLE ID
83616
US

IV. Provider business mailing address

1963 W LONESOME DOVE ST
MERIDIAN ID
83646-8271
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-4080
  • Fax: 208-938-8922
Mailing address:
  • Phone: 208-724-6139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number97391
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number97391
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: