=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598586109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESERET BAKER RND
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2024
-----------------------------------------------------
Last Update Date | 10/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 236 MARTIN ST
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-4444
-----------------------------------------------------
Fax | 208-733-4456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1290 W COASTAL DR
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-5240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-921-9411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 9461273
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------