Healthcare Provider Details

I. General information

NPI: 1225384514
Provider Name (Legal Business Name): DOYLE DRURY CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 11TH AVE E
GOODING ID
83330-5368
US

IV. Provider business mailing address

605 11TH AVE E
GOODING ID
83330-5368
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-8461
  • Fax: 208-934-5437
Mailing address:
  • Phone: 208-934-8461
  • Fax: 208-934-5437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10022
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: