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General NPI Number Information
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NPI Number | 1164827226
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Entity Type | Individual
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Provider Name | OPAL GRIFFIN ATC
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Gender | Female
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Dates
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Enumeration Date | 10/30/2014
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Last Update Date | 10/30/2014
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Provider Practice Location Address
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Address Line | 190 E. BANNOCK STREET
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City | BOISE
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State | ID
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Zip | 83712-9987
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Country | US
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Telephone | 208-381-2222
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Fax |
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Provider Business Mailing Address
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Address Line | 7916 W RYGATE CT
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City | BOISE
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State | ID
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Zip | 83714-6806
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Country | US
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Telephone | 208-850-2799
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT-315
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License Number State | ID
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