Healthcare Provider Details

I. General information

NPI: 1538756135
Provider Name (Legal Business Name): JESSE MICHELLE RUGGLES HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 CHENEY DR W STE 130
TWIN FALLS ID
83301-4099
US

IV. Provider business mailing address

452 CHENEY DR W STE 130
TWIN FALLS ID
83301-4099
US

V. Phone/Fax

Practice location:
  • Phone: 208-404-6764
  • Fax: 208-735-1523
Mailing address:
  • Phone: 208-404-6764
  • Fax: 208-735-1523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA-4207
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: