Healthcare Provider Details

I. General information

NPI: 1649388703
Provider Name (Legal Business Name): KESTA L TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 01/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 E 25TH ST
IDAHO FALLS ID
83404-7542
US

IV. Provider business mailing address

3910 WASHINGTON PKWY
IDAHO FALLS ID
83404-7596
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-1122
  • Fax: 208-523-6025
Mailing address:
  • Phone: 208-523-1122
  • Fax: 208-523-6025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: