Healthcare Provider Details

I. General information

NPI: 1609770593
Provider Name (Legal Business Name): KOLTER ELDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 WOODKING DR
IDAHO FALLS ID
83404-4720
US

IV. Provider business mailing address

3962 CLEARFIELD LN
AMMON ID
83406-8380
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-2255
  • Fax: 208-529-2022
Mailing address:
  • Phone: 307-575-2576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3581637
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: