Healthcare Provider Details

I. General information

NPI: 1639477094
Provider Name (Legal Business Name): MARK BANKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1927 IDAHO ST
LEWISTON ID
83501-2563
US

IV. Provider business mailing address

1927 IDAHO ST
LEWISTON ID
83501-2563
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-8547
  • Fax:
Mailing address:
  • Phone: 208-746-8547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberHA1967
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: