Healthcare Provider Details

I. General information

NPI: 1497226377
Provider Name (Legal Business Name): LINDA KRYSTLE MORALES OVERTON CST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 S MILLENIUM WAY STE 100
MERIDIAN ID
83642-5036
US

IV. Provider business mailing address

3636 W PALOUSE ST
BOISE ID
83705-3244
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-0262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: