Healthcare Provider Details

I. General information

NPI: 1740554237
Provider Name (Legal Business Name): COMMUNITY CARE REXBURG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 E MAIN ST
REXBURG ID
83440-1926
US

IV. Provider business mailing address

72 E MAIN ST
REXBURG ID
83440-1926
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-8448
  • Fax: 208-524-2749
Mailing address:
  • Phone: 208-525-8448
  • Fax: 208-524-2749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberW 110632
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EVELYN ROSSI
Title or Position: PATIENT FINANCIAL SERVICES
Credential: VICE PRESIDENT
Phone: 208-557-2716