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General NPI Number Information
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NPI Number | 1861961732
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Entity Type | Organization
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Legal Business Name | GUSTAVEL ORTHOPEDICS PLLC
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Dates
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Enumeration Date | 11/20/2018
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Last Update Date | 02/28/2019
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Provider Practice Location Address
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Address Line | 1702 W FAIRVIEW AVE
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City | BOISE
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State | ID
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Zip | 83702-5121
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Country | US
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Telephone | 208-957-7400
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Fax |
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Provider Business Mailing Address
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Address Line | 1702 W FAIRVIEW AVE
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City | BOISE
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State | ID
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Zip | 83702-5121
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Country | US
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Telephone | 208-957-7400
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | CINDY YOUNG
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Credential |
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Telephone | 208-957-7400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number |
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License Number State |
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