Provider Demographics
NPI:1336779214
Name:WEST, CORWIN ALLEN (LMT)
Entity Type:Individual
Prefix:
First Name:CORWIN
Middle Name:ALLEN
Last Name:WEST
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 S 1700 W
Mailing Address - Street 2:
Mailing Address - City:PINGREE
Mailing Address - State:ID
Mailing Address - Zip Code:83262-1243
Mailing Address - Country:US
Mailing Address - Phone:208-604-3159
Mailing Address - Fax:
Practice Address - Street 1:920 DEON DR STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3069
Practice Address - Country:US
Practice Address - Phone:208-604-3159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1098225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist