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General NPI Number Information
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NPI Number | 1740319409
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Entity Type | Organization
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Legal Business Name | CENTER FOR COLORECTAL CARE, LLC
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 333 N 1ST ST SUITE 130
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City | BOISE
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State | ID
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Zip | 83702-6100
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Country | US
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Telephone | 770-823-1668
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Fax |
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Provider Business Mailing Address
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Address Line | 333 N 1ST ST SUITE 130
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City | BOISE
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State | ID
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Zip | 83702-6100
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JAMES A OLSON
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Credential | MD
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Telephone | 770-823-1668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | M9825
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License Number State | ID
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