Healthcare Provider Details

I. General information

NPI: 1336220243
Provider Name (Legal Business Name): ROCKY MOUNTAIN DIABETES AND OSTEOPOROSIS CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/27/2009
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: 208-522-2996
  • Fax: 208-523-3318
Mailing address:
  • Phone: 208-522-2996
  • Fax: 208-523-3318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberM4220
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberM9285
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberM7763
License Number StateID

VIII. Authorized Official

Name: JANET M HOOVER
Title or Position: BILLING LEAD
Credential:
Phone: 208-522-2996