Healthcare Provider Details

I. General information

NPI: 1952782914
Provider Name (Legal Business Name): ROCKY MOUNTAIN DIABETES AND OSTEOPOROSIS CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 WASHINGTON PKWY
IDAHO FALLS ID
83404-7596
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: 208-523-0611
Mailing address:
  • Phone: 208-523-1122
  • Fax: 208-523-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-841
License Number StateID

VIII. Authorized Official

Name: JANET M HOOVER
Title or Position: BILLING MANAGER
Credential: CPC
Phone: 208-528-9625