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Idaho County Dermatology, PLLC

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Company Details

Name: Idaho County Dermatology, PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 19 Jun 2024 (a year ago)
Financial Date End: 30 Jun 2025
Entity Number: 5784612
Place of Formation: IDAHO
File Number: 942386
ZIP code: 83530
County: Idaho County
Principal Address: JEANNA RENDO NPC 817 S. A ST GRANGEVILLE, ID 83530
Mailing Address: JEANNA RENDO 113 S A ST GRANGEVILLE, ID 83530-1428

Agent

Name Role Address
Jeanna Rendo Agent 2061 N CONCHA CT, MIDDLETON, ID 83644

National Provider Identifier

NPI Number:
1922835859
Certification Date:
2025-02-07

Authorized Person:

Name:
JEANNA RENDO
Role:
OWNER/PROVIDER
Phone:

Taxonomy:

Selected Taxonomy:
363L00000X - Nurse Practitioner
Is Primary:
Yes

Contacts:

Fax:
2087174990

Filing

Filing Name Filing Number Filing date
Statement of Change of Business Mailing Address 0005909936 2024-09-23
Initial Filing 0005784612 2024-06-19

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Date of last update: 23 May 2025

Sources: Idaho Secretary of State