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General NPI Number Information
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NPI Number | 1770044703
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Entity Type | Organization
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Legal Business Name | TWO RIVERS MEDICAL GROUP
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Dates
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Enumeration Date | 03/31/2019
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Last Update Date | 12/20/2023
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Provider Practice Location Address
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Address Line | 7568 FERRIS AVE
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City | BOISE
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State | ID
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Zip | 83714-5508
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Country | US
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Telephone | 208-283-7691
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1311
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City | EAGLE
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State | ID
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Zip | 83616-1311
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Country | US
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Telephone | 88-283-7691
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Fax |
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Authorized Official
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Title or Position | OWNER, CEO
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Name | ERIN PRETTYWEASEL
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Credential |
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Telephone | 208-283-7691
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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