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General NPI Number Information
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NPI Number | 1346410321
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Entity Type | Organization
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Legal Business Name | CAROL KLETT VANCE MD, INC.
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Dates
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Enumeration Date | 03/06/2008
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Last Update Date | 03/06/2008
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Provider Practice Location Address
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Address Line | 1619 CURLEW DR SUITE 6
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City | AMMON
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State | ID
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Zip | 83406-4719
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Country | US
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Telephone | 208-523-4688
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Fax | 208-523-4990
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Provider Business Mailing Address
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Address Line | 1619 CURLEW DR SUITE 6
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City | AMMON
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State | ID
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Zip | 83406-4719
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Country | US
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Telephone | 208-523-4688
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Fax | 208-523-4990
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Authorized Official
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Title or Position | PHYSICIAN
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Name | CAROL KLETT VANCE
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Credential | M.D.
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Telephone | 208-523-4688
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0008X
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Taxonomy Name | Pediatric Neurodevelopmental Disabilities Physician
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License Number | M9751
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License Number State | ID
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