=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285677278
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOREN KEN ZEITZ CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 06/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 JACOBS GULCH
-----------------------------------------------------
City | KELLOGG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-784-1221
-----------------------------------------------------
Fax | 208-786-1019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 JACOBS GULCH
-----------------------------------------------------
City | KELLOGG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-784-1221
-----------------------------------------------------
Fax | 208-786-7019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | RNA68
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | N-10526
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------