1033424429 NPI number — BORRON FAMILY MEDICINE PLLC

Table of content: (NPI 1033424429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033424429 NPI number — BORRON FAMILY MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BORRON FAMILY MEDICINE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033424429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 W USTICK RD
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83646-5558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-639-3990
Provider Business Mailing Address Fax Number:
208-639-3992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
790 W USTICK RD
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-5558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-639-3990
Provider Business Practice Location Address Fax Number:
208-639-3992
Provider Enumeration Date:
08/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BORRON
Authorized Official First Name:
BROOKNEY
Authorized Official Middle Name:
RAEANNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-866-1428

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: NP-923A , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1033424429 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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