Healthcare Provider Details

I. General information

NPI: 1770502767
Provider Name (Legal Business Name): ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 HOSPITAL WAY BLDG A
POCATELLO ID
83201-2763
US

IV. Provider business mailing address

PO BOX 4788
POCATELLO ID
83205-4788
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-6616
  • Fax: 208-232-6618
Mailing address:
  • Phone: 208-232-6616
  • Fax: 208-232-6618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THOMAS VANCE DAVIS
Title or Position: MEMBER
Credential: D.O.
Phone: 208-232-6616