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General NPI Number Information
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NPI Number | 1114600277
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Entity Type | Organization
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Legal Business Name | IDAHORMONES
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Dates
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Enumeration Date | 08/07/2023
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Last Update Date | 08/07/2023
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Provider Practice Location Address
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Address Line | 3648 N CENTREPOINT WAY STE 110
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City | MERIDIAN
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State | ID
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Zip | 83646-7626
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Country | US
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Telephone | 208-874-2394
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Fax |
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Provider Business Mailing Address
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Address Line | 4954 W GREY TOWERS DR
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City | MERIDIAN
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State | ID
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Zip | 83642-9281
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Country | US
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Telephone | 208-874-2394
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JAMIE RUIZ
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Credential | PA
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Telephone | 208-874-2394
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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