Healthcare Provider Details

I. General information

NPI: 1205291978
Provider Name (Legal Business Name): BRIAN RHODES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 EASTLAND DR
TWIN FALLS ID
83301-6846
US

IV. Provider business mailing address

909 BAILEY AVE
FILER ID
83328-5097
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-4264
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4203
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: