Healthcare Provider Details

I. General information

NPI: 1689631350
Provider Name (Legal Business Name): SUSAN CLAIR CARPENTER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 SHOUP AVE W SUITE B
TWIN FALLS ID
83301-5042
US

IV. Provider business mailing address

PO BOX 587
TWIN FALLS ID
83303-0587
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-9100
  • Fax: 208-814-9903
Mailing address:
  • Phone: 208-814-7400
  • Fax: 208-814-7491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberO-335
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: