Healthcare Provider Details

I. General information

NPI: 1457961229
Provider Name (Legal Business Name): JAMES MCCORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3067 E COPPER POINT DR
MERIDIAN ID
83642-1740
US

IV. Provider business mailing address

12586 W DEEP CANYON DR
STAR ID
83669-5066
US

V. Phone/Fax

Practice location:
  • Phone: 208-287-1733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License NumberPSG-014
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: