Healthcare Provider Details

I. General information

NPI: 1508807926
Provider Name (Legal Business Name): PHYSICIAN CENTER , A PROFESSIONAL COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 03/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 POLE LINE RD W SUITES 105 & 111
TWIN FALLS ID
83301-5814
US

IV. Provider business mailing address

775 POLE LINE RD W SUITES 105 & 111
TWIN FALLS ID
83301-5814
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-8000
  • Fax: 208-733-9402
Mailing address:
  • Phone: 208-814-8000
  • Fax: 208-733-9402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MITCHELL J MOFFITT
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 208-814-8000