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General NPI Number Information
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NPI Number | 1649601006
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Entity Type | Organization
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Legal Business Name | CARMINE PETRACCA
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Dates
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Enumeration Date | 12/10/2013
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Last Update Date | 12/10/2013
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Provider Practice Location Address
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Address Line | 939 BRYDEN AVE
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City | LEWISTON
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State | ID
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Zip | 83501-5057
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Country | US
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Telephone | 208-743-1761
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Fax | 208-746-8042
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Provider Business Mailing Address
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Address Line | 939 BRYDEN AVE
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City | LEWISTON
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State | ID
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Zip | 83501-5057
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Country | US
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Telephone | 208-743-1761
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Fax | 208-746-8042
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Authorized Official
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Title or Position | OWNER
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Name | DR. CARMINE PETRACCA
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Credential | O.D.
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Telephone | 208-743-1761
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | ODP-634
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License Number State | ID
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