Provider Demographics
NPI:1346410321
Name:CAROL KLETT VANCE MD, INC.
Entity Type:Organization
Organization Name:CAROL KLETT VANCE MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:KLETT
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-523-4688
Mailing Address - Street 1:1619 CURLEW DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4719
Mailing Address - Country:US
Mailing Address - Phone:208-523-4688
Mailing Address - Fax:208-523-4990
Practice Address - Street 1:1619 CURLEW DR
Practice Address - Street 2:SUITE 6
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4719
Practice Address - Country:US
Practice Address - Phone:208-523-4688
Practice Address - Fax:208-523-4990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM97512080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807573500Medicaid
ID2618808087OtherCIGNA
ID000010158422OtherREGENCE BLUESHIELD
IDB6254OtherBCBS
WY123868000OtherWYOMING MEDICAID
ID807573500Medicaid