Healthcare Provider Details

I. General information

NPI: 1124740410
Provider Name (Legal Business Name): GERALD ROLIZ MSACN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 E OVERLAND RD STE 220
MERIDIAN ID
83642-8301
US

IV. Provider business mailing address

371 W REDGRAVE DR
MERIDIAN ID
83646-0012
US

V. Phone/Fax

Practice location:
  • Phone: 208-918-1832
  • Fax:
Mailing address:
  • Phone: 208-906-8883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: