Healthcare Provider Details

I. General information

NPI: 1548138688
Provider Name (Legal Business Name): ZACHARY LEON TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 16TH ST
IDAHO FALLS ID
83404-5919
US

IV. Provider business mailing address

111 E 16TH ST
IDAHO FALLS ID
83404-5919
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-1130
  • Fax: 208-529-6501
Mailing address:
  • Phone: 208-523-1130
  • Fax: 208-529-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: