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General NPI Number Information
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NPI Number | 1275790081
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Entity Type | Organization
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Legal Business Name | PASSPORT TO INDEPENDENCE,LLC
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Dates
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Enumeration Date | 05/20/2008
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Last Update Date | 05/20/2008
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Provider Practice Location Address
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Address Line | 764 W HEATHER WOODS DR
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City | NAMPA
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State | ID
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Zip | 83686-2685
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Country | US
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Telephone | 208-461-4882
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Fax |
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Provider Business Mailing Address
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Address Line | 764 W HEATHER WOODS DR
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City | NAMPA
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State | ID
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Zip | 83686-2685
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Country | US
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Telephone | 208-461-4882
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MR. MICHAEL ANTHONY TRIOLO
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Credential | RPH
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Telephone | 208-461-4882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number | OT808
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License Number State | ID
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