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General NPI Number Information
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NPI Number | 1568112688
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Entity Type | Organization
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Legal Business Name | ISSC FRUITLAND
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Dates
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Enumeration Date | 03/24/2022
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Last Update Date | 07/16/2025
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Provider Practice Location Address
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Address Line | 975 NW 16TH ST.
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City | FRUITLAND
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State | ID
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Zip | 83619
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Country | US
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Telephone | 208-452-7450
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Fax | 208-452-7550
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Provider Business Mailing Address
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Address Line | 975 NW 16TH ST.
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City | FRUITLAND
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State | ID
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Zip | 83619
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Country | US
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Telephone | 208-452-7450
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Fax | 208-452-7550
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | CELIA RAMOS
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Credential |
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Telephone | 208-452-7450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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