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General NPI Number Information
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NPI Number | 1700088002
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Entity Type | Organization
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Legal Business Name | CHILDRENS KIDNEY SPECIALISTS PLLC
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 06/20/2012
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Provider Practice Location Address
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Address Line | 100 E IDAHO ST 200
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City | BOISE
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State | ID
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Zip | 83712-6223
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Country | US
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Telephone | 208-381-7336
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Fax | 208-381-7495
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Provider Business Mailing Address
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Address Line | 1935 NW NORFOLK CT
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City | PORTLAND
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State | OR
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Zip | 97229-8448
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Country | US
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Telephone | 503-297-3178
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Fax | 208-381-7495
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. RANDALL JENKINS
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Credential | MD
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Telephone | 208-381-7336
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0210X
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Taxonomy Name | Pediatric Nephrology Physician
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License Number | M6943
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License Number State | ID
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