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General NPI Number Information
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NPI Number | 1154709863
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Entity Type | Organization
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Legal Business Name | CALDWELL IMMEDIATE CARE
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Dates
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Enumeration Date | 05/13/2015
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Last Update Date | 05/26/2015
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Provider Practice Location Address
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Address Line | 2701 CARRIAGE WAY
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City | TWIN FALLS
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State | ID
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Zip | 83301-5257
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Country | US
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Telephone | 208-320-0258
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Fax |
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Provider Business Mailing Address
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Address Line | 2701 CARRIAGE WAY
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City | TWIN FALLS
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State | ID
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Zip | 83301-5257
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Country | US
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Telephone | 208-320-0258
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | MR. JONATHAN BRUCE PITTARD
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Credential | P.A.
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Telephone | 208-320-0258
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | SPHY-345
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License Number State | ID
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