Healthcare Provider Details

I. General information

NPI: 1952660763
Provider Name (Legal Business Name): ADVANCED PODIATRY OF SOUTHERN IDAHO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 07/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 CHENEY DRIVE WEST
TWIN FALLS ID
83301
US

IV. Provider business mailing address

6028 S RIDGELINE DRIVE SUITE 101
OGDEN UT
84405
US

V. Phone/Fax

Practice location:
  • Phone: 208-731-6321
  • Fax: 801-475-5286
Mailing address:
  • Phone: 801-475-5239
  • Fax: 801-475-5286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number8015238-0501
License Number StateUT

VIII. Authorized Official

Name: TAWNA H GOULDING
Title or Position: ADMINISTRATOR
Credential:
Phone: 801-475-5239