1275512246 NPI number — MRS. GLORIA GOULD GUNTER MPT, MED, PCS

Table of content: MRS. GLORIA GOULD GUNTER MPT, MED, PCS (NPI 1275512246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275512246 NPI number — MRS. GLORIA GOULD GUNTER MPT, MED, PCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNTER
Provider First Name:
GLORIA
Provider Middle Name:
GOULD
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT, MED, PCS
Provider Gender Code:
F

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:
1275512246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 92
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAILEY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83333-0092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-720-3421
Provider Business Mailing Address Fax Number:
208-297-2680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 E BULLION ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
HAILEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83333-8770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-720-3421
Provider Business Practice Location Address Fax Number:
208-297-2680
Provider Enumeration Date:
01/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  RPT1204 , 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: T4868 . This is a "BLUE CROSS OF IDAHO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000010030447 . This is a "BLUE SHIELD OF IDAHO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1275512246 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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