Provider Demographics
NPI:1184329070
Name:NVELUP IDAHO CORP
Entity type:Organization
Organization Name:NVELUP IDAHO CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:DI LELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-510-6030
Mailing Address - Street 1:PO BOX 7221
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94955-7221
Mailing Address - Country:US
Mailing Address - Phone:415-324-9906
Mailing Address - Fax:
Practice Address - Street 1:3597 E MONARCH SKY LN STE 240-8464
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1053
Practice Address - Country:US
Practice Address - Phone:208-510-6030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-31
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty