Healthcare Provider Details

I. General information

NPI: 1780062588
Provider Name (Legal Business Name): KEZELE ANESTHETICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 VISTA DR
POCATELLO ID
83201-4987
US

IV. Provider business mailing address

104 N BEAR RIVER BLFS
PRESTON ID
83263-5184
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-1704
  • Fax:
Mailing address:
  • Phone: 208-852-2019
  • Fax: 208-852-7173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-366A
License Number StateID

VIII. Authorized Official

Name: MR. JOHN THOMAS KEZELE III
Title or Position: PRESIDENT
Credential: CRNA
Phone: 208-852-2019