Healthcare Provider Details

I. General information

NPI: 1508920869
Provider Name (Legal Business Name): RICHARD LEE MITTELSTEDT R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 MISSION RD
FORT HALL ID
83203-0717
US

IV. Provider business mailing address

717 MISSION ROAD
FORT HALL ID
83203
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-5427
  • Fax: 208-238-5427
Mailing address:
  • Phone: 208-238-5427
  • Fax: 208-238-5427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberN-32836
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: