Healthcare Provider Details

I. General information

NPI: 1437749082
Provider Name (Legal Business Name): BRYCE C JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1248 E 17TH ST
IDAHO FALLS ID
83404-6147
US

IV. Provider business mailing address

3900 E IONA RD
IDAHO FALLS ID
83401-5000
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-1026
  • Fax:
Mailing address:
  • Phone: 208-520-2713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: