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Organization
BURN AND RECONSTRUCTIVE CENTERS OF IDAHO, PLLC
Active
Organization
BURN AND RECONSTRUCTIVE CENTERS OF IDAHO, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHAWN FAGAN (OWNER/MD)
(706) 863-9595
Entity
Organization
Contact information
Practice address
3100 CHANNING WAY, IDAHO FALLS, ID 83404-7533
(706) 863-9595
(706) 868-8375
Mailing address
PO BOX 12358, AUGUSTA, GA 30914-2358
(706) 863-9595
(706) 868-8375
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
NULL
174400000X
Specialist
Primary
—
—
Other
Enumeration date
01/28/2019
Last updated
10/11/2022
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