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General NPI Number Information
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NPI Number | 1285271635
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Entity Type | Organization
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Legal Business Name | TREASURE VALLEY METABOLIC MEDICINE
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Dates
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Enumeration Date | 12/04/2019
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Last Update Date | 03/23/2021
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Provider Practice Location Address
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Address Line | 951 E PLAZA DR STE 110
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City | EAGLE
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State | ID
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Zip | 83616-6567
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Country | US
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Telephone | 208-274-9580
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Fax | 208-274-9581
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Provider Business Mailing Address
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Address Line | 951 E PLAZA DR STE 110
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City | EAGLE
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State | ID
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Zip | 83616-6567
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Country | US
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Telephone | 208-274-9580
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Fax | 208-274-9581
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Authorized Official
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Title or Position | CEO, OWNER
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Name | KATY CONNLEY
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Credential |
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Telephone | 208-830-6773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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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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