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General NPI Number Information
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NPI Number | 1801350590
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Entity Type | Organization
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Legal Business Name | THE PEDIATRIC PLACE
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Dates
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Enumeration Date | 01/26/2019
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Last Update Date | 11/08/2021
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Provider Practice Location Address
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Address Line | 1236 BOND AVE STE B
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City | REXBURG
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State | ID
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Zip | 83440-3503
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Country | US
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Telephone | 208-701-0277
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Fax | 208-701-0294
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Provider Business Mailing Address
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Address Line | 1236 BOND AVE STE B
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City | REXBURG
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State | ID
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Zip | 83440-3503
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Country | US
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Telephone | 208-701-0277
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Fax |
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Authorized Official
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Title or Position | PEDIATRICIAN
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Name | DR. ABRAM COLLARD
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Credential | DO
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Telephone | 208-701-0277
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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