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General NPI Number Information
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NPI Number | 1376729541
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Entity Type | Organization
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Legal Business Name | STANLEY J. CHESLOCK, M.D., P.A.
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Dates
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Enumeration Date | 01/17/2008
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Last Update Date | 01/17/2008
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Provider Practice Location Address
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Address Line | 2860 CHANNING WAY SUITE 224
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7531
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Country | US
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Telephone | 208-529-6430
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Fax | 208-529-6428
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Provider Business Mailing Address
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Address Line | 2860 CHANNING WAY SUITE 224
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7531
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Country | US
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Telephone | 208-529-6430
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Fax | 208-529-6428
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Authorized Official
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Title or Position | OWNER, PRESIDENT
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Name | DR. STANLEY J CHESLOCK
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Credential | M.D.
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Telephone | 208-529-6430
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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 | M3570
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License Number State | ID
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