Provider Demographics
NPI:1659804086
Name:BARBOUR, A VANCE
Entity Type:Individual
Prefix:
First Name:A VANCE
Middle Name:
Last Name:BARBOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 W LOCKHEED LN # EE30450
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-6509
Mailing Address - Country:US
Mailing Address - Phone:307-429-2639
Mailing Address - Fax:
Practice Address - Street 1:2622 W LOCKHEED LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-6509
Practice Address - Country:US
Practice Address - Phone:307-429-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY225700000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist