Healthcare Provider Details

I. General information

NPI: 1649174194
Provider Name (Legal Business Name): MARIO AVILA HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 S WOODRUFF AVE
IDAHO FALLS ID
83404-8305
US

IV. Provider business mailing address

3240 S WOODRUFF AVE
IDAHO FALLS ID
83404-8305
US

V. Phone/Fax

Practice location:
  • Phone: 208-974-5200
  • Fax: 208-936-7004
Mailing address:
  • Phone: 208-974-5200
  • Fax: 208-936-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: