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General NPI Number Information
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NPI Number | 1588861405
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Entity Type | Organization
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Legal Business Name | PODIATRY SERVICES OF IDAHO, PLLC
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Dates
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Enumeration Date | 07/03/2007
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Last Update Date | 03/01/2022
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Provider Practice Location Address
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Address Line | 229 E LOGAN ST
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City | CALDWELL
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State | ID
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Zip | 83605-4835
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Country | US
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Telephone | 208-402-6587
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Fax | 84-026-5782
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Provider Business Mailing Address
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Address Line | 1105 E USTICK RD
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City | CALDWELL
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State | ID
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Zip | 83605-6306
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Country | US
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Telephone | 208-402-6587
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Fax | 208-402-6578
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Authorized Official
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Title or Position | CEO
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Name | DR. CAMILLE ELIZABETH HARRIS
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Credential | DPM
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Telephone | 208-402-6587
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | DP00359
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License Number State | OR
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