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General NPI Number Information
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NPI Number | 1902048879
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Entity Type | Organization
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Legal Business Name | RENCHER FAMILY PRACTICE, PA
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Dates
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Enumeration Date | 03/24/2009
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Last Update Date | 03/24/2009
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Provider Practice Location Address
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Address Line | 2610 CHANNING WAY
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7517
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Country | US
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Telephone | 208-523-0888
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Fax |
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Provider Business Mailing Address
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Address Line | 2610 CHANNING WAY
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City | IDAHO FALLS
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State | ID
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Zip | 83404
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Country | US
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Telephone | 208-523-0888
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MARK B RENCHER
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Credential | M.D.
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Telephone | 208-523-0888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | M4486
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License Number State | ID
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