Healthcare Provider Details

I. General information

NPI: 1740678234
Provider Name (Legal Business Name): TUNDRA MCDOUGAL I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 SW 5TH AVENUE
MERIDIAN ID
83642
US

IV. Provider business mailing address

179 SW 5TH AVENUE
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-8282
  • Fax:
Mailing address:
  • Phone: 208-367-8282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1283
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: