Healthcare Provider Details

I. General information

NPI: 1528551751
Provider Name (Legal Business Name): RYAN D KAINRATH IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR
MOUNTAIN HOME AFB ID
83648-1057
US

IV. Provider business mailing address

930 GARRETT ST
MOUNTAIN HOME ID
83647-3696
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-7100
  • Fax:
Mailing address:
  • Phone: 630-788-5482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: