Healthcare Provider Details

I. General information

NPI: 1013423482
Provider Name (Legal Business Name): HANDS ON DIAGNOSTICS OF IDAHO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 FLANDRO DR STE 190
POCATELLO ID
83202-4940
US

IV. Provider business mailing address

723 REDMAN ST
POCATELLO ID
83202-2673
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2248
  • Fax:
Mailing address:
  • Phone: 208-233-2248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BART W MCDONALD
Title or Position: OWNER
Credential: MPT
Phone: 208-233-2248