Healthcare Provider Details

I. General information

NPI: 1952493249
Provider Name (Legal Business Name): WMCESA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 12TH AVE. RD STE. B
NAMPA ID
83686
US

IV. Provider business mailing address

1603 12TH AVE. RD STE. B
NAMPA ID
83686
US

V. Phone/Fax

Practice location:
  • Phone: 208-467-2400
  • Fax: 208-467-6416
Mailing address:
  • Phone: 208-467-2400
  • Fax: 208-467-6416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. GERALD CARLSON
Title or Position: SUPERVISING DR
Credential: D.O
Phone: 208-467-2400