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General NPI Number Information
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NPI Number | 1841550126
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Entity Type | Organization
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Legal Business Name | ESSENTIAL LIFE BOISE
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Dates
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Enumeration Date | 05/21/2012
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Last Update Date | 08/27/2012
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Provider Practice Location Address
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Address Line | 13125 W PERSIMMON LN STE 100
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City | BOISE
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State | ID
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Zip | 83713-2086
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Country | US
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Telephone | 208-991-0352
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Fax |
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Provider Business Mailing Address
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Address Line | 13125 W PERSIMMON LN STE 100
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City | BOISE
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State | ID
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Zip | 83713-2086
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. YVONNE FEDEWA
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Credential |
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Telephone | 208-991-0352
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | CHIA1466
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License Number State | ID
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