Healthcare Provider Details

I. General information

NPI: 1912833138
Provider Name (Legal Business Name): EASTON BLEVIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N ARTHUR AVE
POCATELLO ID
83204-2803
US

IV. Provider business mailing address

805 N ARTHUR AVE
POCATELLO ID
83204-2803
US

V. Phone/Fax

Practice location:
  • Phone: 208-760-2144
  • Fax:
Mailing address:
  • Phone: 208-760-2144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: