Healthcare Provider Details

I. General information

NPI: 1356245104
Provider Name (Legal Business Name): BRUCE FRANKLIN BREEDLOVE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 2ND AVE N
TWIN FALLS ID
83301-5746
US

IV. Provider business mailing address

704 2ND AVE N
TWIN FALLS ID
83301-5746
US

V. Phone/Fax

Practice location:
  • Phone: 208-207-9422
  • Fax:
Mailing address:
  • Phone: 208-207-9422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1581938
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: