Healthcare Provider Details

I. General information

NPI: 1184431660
Provider Name (Legal Business Name): DIRECT CONNECT IDAHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5584 W OLD RANCH ST
GARDEN CITY ID
83714-1839
US

IV. Provider business mailing address

2976 E STATE ST STE 120-1039
EAGLE ID
83616-6377
US

V. Phone/Fax

Practice location:
  • Phone: 208-314-2631
  • Fax:
Mailing address:
  • Phone: 208-314-2631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: ZECHARIAH BAKER
Title or Position: PRESIDENT
Credential:
Phone: 208-314-2631