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General NPI Number Information
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NPI Number | 1588987812
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Entity Type | Individual
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Provider Name | MR. COURT T CHURCH
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Gender | Male
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Dates
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Enumeration Date | 03/01/2010
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Last Update Date | 03/01/2010
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Provider Practice Location Address
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Address Line | 2725 E 17TH ST
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City | AMMON
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State | ID
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Zip | 83406-6601
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Country | US
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Telephone | 208-529-4567
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Fax |
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Provider Business Mailing Address
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Address Line | 2667 AQUA MARINE DR
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City | IDAHO FALLS
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State | ID
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Zip | 83401-6228
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Country | US
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Telephone | 208-351-1085
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT898
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License Number State | ID
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