Healthcare Provider Details

I. General information

NPI: 1063578664
Provider Name (Legal Business Name): DOCTORS CLINIC OF ELMORE COUNTY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 AMERICAN LEGION BLVD
MOUNTAIN HOME ID
83647-3138
US

IV. Provider business mailing address

2000 AMERICAN LEGION BLVD
MOUNTAIN HOME ID
83647-3138
US

V. Phone/Fax

Practice location:
  • Phone: 208-587-1500
  • Fax: 208-587-3180
Mailing address:
  • Phone: 208-587-1500
  • Fax: 208-587-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-265
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-91
License Number StateID

VIII. Authorized Official

Name: DR. LAYNE D ROBERTS
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 208-587-1500