Healthcare Provider Details

I. General information

NPI: 1881816304
Provider Name (Legal Business Name): IVAN M HARDCASTLE MOT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 EASTLAND DR N STE A
TWIN FALLS ID
83301-4458
US

IV. Provider business mailing address

276 EASTLAND DR N STE A
TWIN FALLS ID
83301-4458
US

V. Phone/Fax

Practice location:
  • Phone: 208-308-4661
  • Fax: 208-736-0890
Mailing address:
  • Phone: 208-308-4661
  • Fax: 208-736-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTLP240
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-831
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: