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General NPI Number Information
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NPI Number | 1609296326
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Entity Type | Organization
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Legal Business Name | MAGIC VALLEY FOOT AND ANKLE SPECIALISTS PLLC
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Dates
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Enumeration Date | 04/21/2014
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Last Update Date | 07/02/2014
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Provider Practice Location Address
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Address Line | 496 SHOUP AVE W
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City | TWIN FALLS
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State | ID
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Zip | 83301-5834
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Country | US
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Telephone | 208-709-1700
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Fax |
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Provider Business Mailing Address
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Address Line | 496 SHOUP AVE W
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City | TWIN FALLS
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State | ID
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Zip | 83301-5834
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Country | US
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Telephone | 208-709-1700
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CALEB ROBERTS
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Credential | DPM
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Telephone | 208-709-1700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | CS35833
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License Number State | ID
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