=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508517764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICK WALSH JR. OWNER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2022
-----------------------------------------------------
Last Update Date | 01/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3597 E MONARCH SKY LN STE 240
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-1055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-893-6099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3597 E MONARCH SKY LN STE 240
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-1055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-893-6099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------