=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982275988
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHELLE HUNTER CNIM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2021
-----------------------------------------------------
Last Update Date | 07/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4205 COCHISE DRIVE
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-569-8623
-----------------------------------------------------
Fax | 855-463-7123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1110 YELLOWSTONE AVE # 191
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83201-4312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-569-8623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZE0600X
-----------------------------------------------------
Taxonomy Name | Electroneurodiagnostic Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------