Healthcare Provider Details

I. General information

NPI: 1952324188
Provider Name (Legal Business Name): COMMUNITY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 E 1ST S
RIGBY ID
83442-1401
US

IV. Provider business mailing address

167 E 1ST S
RIGBY ID
83442-1401
US

V. Phone/Fax

Practice location:
  • Phone: 208-745-8747
  • Fax: 208-745-9396
Mailing address:
  • Phone: 208-745-8747
  • Fax: 208-745-9396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RYAN PETERSON
Title or Position: CEO
Credential:
Phone: 208-525-8448