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General NPI Number Information
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NPI Number | 1801567029
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Entity Type | Organization
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Legal Business Name | ADD CLINIC OF IDAHO
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Dates
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Enumeration Date | 09/27/2021
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Last Update Date | 09/27/2021
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Provider Practice Location Address
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Address Line | 1450 W USTICK RD UNIT 102
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City | MERIDIAN
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State | ID
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Zip | 83646
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Country | US
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Telephone | 858-207-8861
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Fax |
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Provider Business Mailing Address
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Address Line | 330 W ANTON DR
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City | MERIDIAN
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State | ID
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Zip | 83646-2066
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Country | US
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Telephone | 858-207-8861
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CODY D MATTINGLY
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Credential | PA-C
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Telephone | 858-207-8861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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