Healthcare Provider Details

I. General information

NPI: 1235470196
Provider Name (Legal Business Name): BONNIE COLLEEN CAYWOOD RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 S 5TH ST
MONTPELIER ID
83254-1557
US

IV. Provider business mailing address

164 S 5TH ST
MONTPELIER ID
83254-1557
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-1630
  • Fax: 208-847-4334
Mailing address:
  • Phone: 208-847-1630
  • Fax: 208-847-4334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-376
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberD-376
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: