=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740532068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES VERNON TOONE OT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2012
-----------------------------------------------------
Last Update Date | 05/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2656 E MAGIC VIEW DR
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-6243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-996-2801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 871 E 4TH ST
-----------------------------------------------------
City | KUNA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83634-2152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-948-7035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT-2102
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------