Provider Demographics
NPI:1407748510
Name:EAST IDAHO WOUND CARE LLC
Entity type:Organization
Organization Name:EAST IDAHO WOUND CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:KYLER
Authorized Official - Last Name:CROFT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:208-541-8879
Mailing Address - Street 1:1005 TERRY DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5122
Mailing Address - Country:US
Mailing Address - Phone:208-541-8879
Mailing Address - Fax:
Practice Address - Street 1:1005 TERRY DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5122
Practice Address - Country:US
Practice Address - Phone:208-541-8879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty