Healthcare Provider Details

I. General information

NPI: 1871103499
Provider Name (Legal Business Name): KYLIN KOVAC DPM PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

393 E 2ND N
REXBURG ID
83440-1605
US

IV. Provider business mailing address

1540 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-8393
  • Fax:
Mailing address:
  • Phone: 208-529-8393
  • Fax: 208-529-8398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: KYLIN KOVAC
Title or Position: OWNER, PHYSICIAN
Credential: DPM
Phone: 208-529-8393