Healthcare Provider Details

I. General information

NPI: 1912481292
Provider Name (Legal Business Name): FALLS AVENUE IMMEDIATE CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 FALLS AVE STE D
TWIN FALLS ID
83301-3370
US

IV. Provider business mailing address

260 FALLS AVE STE D
TWIN FALLS ID
83301-3370
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-6700
  • Fax: 208-733-0803
Mailing address:
  • Phone: 208-733-6700
  • Fax: 208-733-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: W SCOTT RUDEEN
Title or Position: OWNER
Credential: MD
Phone: 208-733-6700