Provider Demographics
NPI:1447580428
Name:FULL OF LIFE 5580
Entity Type:Organization
Organization Name:FULL OF LIFE 5580
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-521-0155
Mailing Address - Street 1:697 E 1600 N
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5752
Mailing Address - Country:US
Mailing Address - Phone:208-521-0155
Mailing Address - Fax:208-357-7516
Practice Address - Street 1:697 E 1600 N
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-5752
Practice Address - Country:US
Practice Address - Phone:208-521-0155
Practice Address - Fax:208-357-7516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID003513710-S332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003513710-SOtherSELLER'S PERMIT