=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467663328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUPUYTREN'S CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 351 SW 9TH ST
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97914-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-344-5628
-----------------------------------------------------
Fax | 208-345-2907
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1007 N 6TH ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702-4339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JILL MALLOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-344-5628
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | DO14247
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------