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General NPI Number Information
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NPI Number | 1023902533
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Entity Type | Individual
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Provider Name | SAMUEL DUSTIN PAYNE
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Gender | Male
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Dates
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Enumeration Date | 06/07/2025
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Last Update Date | 06/07/2025
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Provider Practice Location Address
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Address Line | 1820 E 17TH ST STE 330
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6400
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Country | US
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Telephone | 208-497-0685
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Fax |
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Provider Business Mailing Address
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Address Line | 555 W MIKAN DR APT 12202
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City | REXBURG
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State | ID
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Zip | 83440-8056
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Country | US
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Telephone | 208-760-5688
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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