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General NPI Number Information
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NPI Number | 1649410218
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Entity Type | Organization
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Legal Business Name | BOISE LASER AND COSMETIC SURGERY CENTER PC
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Dates
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Enumeration Date | 02/23/2009
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Last Update Date | 11/08/2010
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Provider Practice Location Address
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Address Line | 6077 N EAGLE RD
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City | BOISE
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State | ID
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Zip | 83713-0997
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Country | US
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Telephone | 208-939-9000
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Fax | 208-939-9580
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Provider Business Mailing Address
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Address Line | 6077 N EAGLE RD
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City | BOISE
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State | ID
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Zip | 83713-0997
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Country | US
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Telephone | 208-939-9000
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Fax | 208-939-9580
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Authorized Official
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Title or Position | PHYSICIAN
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Name | BRET J RODGERS
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Credential | M.D.
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Telephone | 208-939-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YS0123X
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Taxonomy Name | Facial Plastic Surgery Physician
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License Number |
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License Number State |
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