Healthcare Provider Details

I. General information

NPI: 1821207580
Provider Name (Legal Business Name): FIRM FOUINDATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2496 MESA ST
IDAHO FALLS ID
83401-3369
US

IV. Provider business mailing address

2496 MESA ST
IDAHO FALLS ID
83401-3369
US

V. Phone/Fax

Practice location:
  • Phone: 208-251-7885
  • Fax: 208-745-0527
Mailing address:
  • Phone: 208-251-7885
  • Fax: 208-745-0527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JESSE PETERSON
Title or Position: CO-OWNER
Credential: MS
Phone: 208-251-7885