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General NPI Number Information
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NPI Number | 1518547140
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Entity Type | Organization
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Legal Business Name | BOISE KETAMINE CLINIC
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Dates
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Enumeration Date | 04/08/2021
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Last Update Date | 04/08/2021
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Provider Practice Location Address
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Address Line | 2800 W OVERLAND RD
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City | BOISE
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State | ID
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Zip | 83705-3038
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Country | US
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Telephone | 208-801-1414
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Fax | 208-207-2866
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Provider Business Mailing Address
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Address Line | 2800 W OVERLAND RD
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City | BOISE
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State | ID
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Zip | 83705-3038
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Country | US
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Telephone | 208-801-1414
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Fax | 208-207-2866
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Authorized Official
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Title or Position | OWNER
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Name | NYKOL BAILEY
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Credential | CRNA
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Telephone | 208-801-1414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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