=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982015822
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH C ROMNEY MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2014
-----------------------------------------------------
Last Update Date | 05/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 526 SHOUP AVE W STE E
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-5050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-736-3362
-----------------------------------------------------
Fax | 208-736-3382
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 526 SHOUP AVE W STE E
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-5050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-736-3362
-----------------------------------------------------
Fax | 208-736-3382
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KENNETH CHARLES ROMNEY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 208-736-3362
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | M-11134
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------