Healthcare Provider Details

I. General information

NPI: 1336068618
Provider Name (Legal Business Name): SAMANTHA J. BEDOLLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1246 YELLOWSTONE AVE STE C5
POCATELLO ID
83201-4373
US

IV. Provider business mailing address

566 RANDOLPH AVE
POCATELLO ID
83201-3933
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-0150
  • Fax:
Mailing address:
  • Phone: 208-546-8213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number8081510
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: