Provider Demographics
NPI:1265783419
Name:BELL, B GARY (AS, CMT)
Entity type:Individual
Prefix:
First Name:B
Middle Name:GARY
Last Name:BELL
Suffix:
Gender:M
Credentials:AS, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83725-1351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1529 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-0001
Practice Address - Country:US
Practice Address - Phone:208-426-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID820290701261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health