Healthcare Provider Details

I. General information

NPI: 1932523164
Provider Name (Legal Business Name): OWENS MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S BONITO WAY
MERIDIAN ID
83642-1659
US

IV. Provider business mailing address

PO BOX 1078
BURLEY ID
83318-0947
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 208-219-9562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM-10394
License Number StateID

VIII. Authorized Official

Name: KEVIN OWENS
Title or Position: OWNER
Credential: M.D.
Phone: 208-219-9562