Healthcare Provider Details

I. General information

NPI: 1659029411
Provider Name (Legal Business Name): PCS PROCEDURE SUITE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 VISTA DR
POCATELLO ID
83201-5824
US

IV. Provider business mailing address

110 VISTA DR
POCATELLO ID
83201-5824
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-2300
  • Fax: 208-234-0026
Mailing address:
  • Phone: 208-234-2300
  • Fax: 208-234-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK L MANSFIELD
Title or Position: OWNER
Credential: MD
Phone: 208-234-2300