Healthcare Provider Details

I. General information

NPI: 1750961637
Provider Name (Legal Business Name): SENIOR DOC IDAHO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 GARRITY BLVD STE 103
NAMPA ID
83687-9222
US

IV. Provider business mailing address

5 HUTTON CENTRE DR STE 950
SANTA ANA CA
92707-8714
US

V. Phone/Fax

Practice location:
  • Phone: 855-434-7763
  • Fax: 949-281-5550
Mailing address:
  • Phone: 558-434-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN GEISS
Title or Position: OWNER/DOCTOR
Credential:
Phone: 855-434-7763