Provider Demographics
NPI:1366767790
Name:GUERRA, ELISEO
Entity type:Individual
Prefix:
First Name:ELISEO
Middle Name:
Last Name:GUERRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 I STEET
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401
Mailing Address - Country:US
Mailing Address - Phone:208-252-0081
Mailing Address - Fax:
Practice Address - Street 1:457 I ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2842
Practice Address - Country:US
Practice Address - Phone:208-252-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist