Healthcare Provider Details

I. General information

NPI: 1962916304
Provider Name (Legal Business Name): FALLS CENTRE FOR FUNCTIONAL MEDICINE, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 MARTIN ST
TWIN FALLS ID
83301-4542
US

IV. Provider business mailing address

236 MARTIN ST
TWIN FALLS ID
83301-4542
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-4444
  • Fax: 208-733-4456
Mailing address:
  • Phone: 208-733-4444
  • Fax: 208-733-4456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-180
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberO-180
License Number StateID

VIII. Authorized Official

Name: GEOFFREY NEIL HICKS
Title or Position: PROVIDER
Credential: NP-C
Phone: 208-733-4444