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General NPI Number Information
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NPI Number | 1144783499
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Entity Type | Organization
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Legal Business Name | MOUNTAIN STATES DIABETES RELIEF, LLC
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Dates
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Enumeration Date | 04/12/2019
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Last Update Date | 04/12/2019
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Provider Practice Location Address
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Address Line | 4573 E MAJESTIC
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City | IDAHO FALLS
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State | ID
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Zip | 83406
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Country | US
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Telephone | 208-520-2636
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Fax |
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Provider Business Mailing Address
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Address Line | 4573 E MAJESTIC
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City | IDAHO FALLS
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State | ID
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Zip | 83406
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Country | US
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Telephone | 208-520-2636
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | KATIE DAVENPORT
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Credential |
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Telephone | 208-520-2636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number |
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License Number State |
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