Provider Demographics
NPI:1073323176
Name:KOOMPIN, AMBER (LMT, MMP, CIMI)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:KOOMPIN
Suffix:
Gender:
Credentials:LMT, MMP, CIMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 NEELEY LOOP
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83211-5532
Mailing Address - Country:US
Mailing Address - Phone:208-339-3655
Mailing Address - Fax:
Practice Address - Street 1:845 W CENTER ST STE L201
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-4205
Practice Address - Country:US
Practice Address - Phone:208-244-0941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-10
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3531225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist