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General NPI Number Information
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NPI Number | 1457015422
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Entity Type | Organization
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Legal Business Name | TRAILHEAD MEDICAL GROUP LLC
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Dates
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Enumeration Date | 10/26/2021
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Last Update Date | 01/30/2023
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Provider Practice Location Address
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Address Line | 2269 E GRAYSON ST
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City | MERIDIAN
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State | ID
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Zip | 83642-5348
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Country | US
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Telephone | 208-841-7020
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Fax |
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Provider Business Mailing Address
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Address Line | 2269 E GRAYSON ST
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City | MERIDIAN
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State | ID
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Zip | 83642-5348
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Country | US
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Telephone | 208-841-7020
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHASE C CHRISTOFFERSEN
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Credential |
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Telephone | 208-841-7020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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