Organization
CAROL KLETT VANCE MD, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CAROL KLETT VANCE M.D. (PHYSICIAN)
(208) 523-4688
Entity
Organization
Contact information
Practice address
1619 CURLEW DR, SUITE 6, AMMON, ID 83406-4719
(208) 523-4688
(208) 523-4990
Mailing address
1619 CURLEW DR, SUITE 6, AMMON, ID 83406-4719
(208) 523-4688
(208) 523-4990
Taxonomy
Speciality
Code
Description
License number
State
2080P0008X
Pediatric Neurodevelopmental Disabilities Physician
Primary
M9751
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010158422
REGENCE BLUESHIELD
ID
01
—
123868000
WYOMING MEDICAID
WY
01
—
2618808087
CIGNA
ID
05
—
807573500
—
ID
01
—
B6254
BCBS
ID
Enumeration date
03/06/2008
Last updated
03/06/2008
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