Healthcare Provider Details

I. General information

NPI: 1386875268
Provider Name (Legal Business Name): FRED ELMER GIOVANINI L.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 1ST STREET, SUITE A
IDAHO FALLS ID
83401
US

IV. Provider business mailing address

505 1ST ST SUITE A
IDAHO FALLS ID
83401-3929
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-6002
  • Fax: 208-232-2558
Mailing address:
  • Phone: 208-525-6002
  • Fax: 208-232-2558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberLD35
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: