Healthcare Provider Details

I. General information

NPI: 1497741383
Provider Name (Legal Business Name): LORRAINE C NOVICH-WELTER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LORI CN WELTER MD

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 N 1ST E STE 200
PRESTON ID
83263-1326
US

IV. Provider business mailing address

64 N 1ST E STE 200
PRESTON ID
83263-1326
US

V. Phone/Fax

Practice location:
  • Phone: 208-852-3662
  • Fax:
Mailing address:
  • Phone: 208-852-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberM-10473
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5924248-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: