Healthcare Provider Details

I. General information

NPI: 1881118941
Provider Name (Legal Business Name): KISMET PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 E JACKSON ST
MOUNTAIN HOME ID
83647
US

IV. Provider business mailing address

280 E JACKSON ST
MOUNTAIN HOME ID
83647-2708
US

V. Phone/Fax

Practice location:
  • Phone: 208-991-8487
  • Fax:
Mailing address:
  • Phone: 208-991-8487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT-2466
License Number StateID

VIII. Authorized Official

Name: DAREN A STAFFORD
Title or Position: OWNER/PROVIDER
Credential: DPT
Phone: 208-991-8487