Healthcare Provider Details

I. General information

NPI: 1740120583
Provider Name (Legal Business Name): WOUND & SKIN CARE OF IDAHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

IV. Provider business mailing address

1542 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

V. Phone/Fax

Practice location:
  • Phone: 986-275-0142
  • Fax: 307-333-0299
Mailing address:
  • Phone: 986-275-0142
  • Fax: 307-333-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code364SC2300X
TaxonomyChronic Care Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA LAIRD-ROGERS
Title or Position: CEO
Credential: FNP-C
Phone: 307-259-9269