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NPI Code Detail

MEDICARE: KENNETH EDWARD SQUIRES III D.O.

MEDICARE: KENNETH EDWARD SQUIRES III D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12084P0800XPsychiatry PhysicianPG183059OR
22084P0800XPsychiatry PhysicianO-1978ID

General Provider Information

NPI Number : 1649706326
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNETH EDWARD SQUIRES III D.O.
Provider Business Mailing Address
First Line : PO BOX 190930
Second Line :
City : BOISE
State : ID
Zip : 83719-0930
Country : US
Telephone Number : 208-367-5170
Fax Number : 208-367-5180
Provider Business Practice Location Address
First Line : 6348 W EMERALD ST
Second Line :
City : BOISE
State : ID
Zip : 83704-8732
Country : US
Telephone Number : 208-302-0900
Fax Number : 208-302-0955
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/02/2017
Last Update Date : 05/15/2024

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Directions to “ KENNETH EDWARD SQUIRES III D.O.” Practice Location

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