=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952141418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOISE VALLEY ANESTHESIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2024
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1828 S MILLENIUM WAY
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-5036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-381-0262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2291
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83403-2291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-338-5378
-----------------------------------------------------
Fax | 208-523-8978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TATIANA KHOCHAY
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 208-794-1559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------