Healthcare Provider Details

I. General information

NPI: 1003088782
Provider Name (Legal Business Name): COMMUNITY CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 YELLOWSTONE AVE
POCATELLO ID
83201
US

IV. Provider business mailing address

1595 YELLOWSTONE AVE
POCATELLO ID
83201
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-0032
  • Fax:
Mailing address:
  • Phone: 208-233-0032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: RYAN L PETERSON
Title or Position: CEO
Credential:
Phone: 208-525-8448