Healthcare Provider Details

I. General information

NPI: 1306024120
Provider Name (Legal Business Name): IDAHO FOOT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

IV. Provider business mailing address

1540 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-8393
  • Fax: 208-529-8398
Mailing address:
  • Phone: 208-529-8393
  • Fax: 208-529-8398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP93
License Number StateID

VIII. Authorized Official

Name: DR. BRUCE G TOLMAN
Title or Position: OWNER
Credential: DPM
Phone: 208-529-8393