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General NPI Number Information
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NPI Number | 1801023643
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Entity Type | Organization
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Legal Business Name | IDAHO SPORTS BRACING INC
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Dates
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Enumeration Date | 06/19/2009
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Last Update Date | 06/19/2009
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Provider Practice Location Address
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Address Line | 711 N RALSTIN ST
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City | MERIDIAN
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State | ID
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Zip | 83642-4079
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Country | US
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Telephone | 208-887-9071
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Fax | 208-887-9235
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Provider Business Mailing Address
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Address Line | PO BOX 625
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City | MERIDIAN
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State | ID
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Zip | 83680-0625
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Country | US
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Telephone | 208-887-9071
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Fax | 208-887-9235
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Authorized Official
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Title or Position | SECRETARY TREASURER
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Name | MRS. DANNETTE M PETERSON
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Credential |
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Telephone | 208-887-9071
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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