Healthcare Provider Details

I. General information

NPI: 1649081233
Provider Name (Legal Business Name): ROSALINDA CRUZ BOURASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2265 W BROADWAY ST
IDAHO FALLS ID
83402-2996
US

IV. Provider business mailing address

2265 W BROADWAY ST
IDAHO FALLS ID
83402-2996
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-7400
  • Fax:
Mailing address:
  • Phone: 208-524-7400
  • Fax: 208-524-8004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5371745
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: