1891734729 NPI number — IDAHO HAND AND WRIST

Table of content: (NPI 1891734729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891734729 NPI number — IDAHO HAND AND WRIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDAHO HAND AND WRIST
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:
1891734729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1520 W STATE ST
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83702-4038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-287-1110
Provider Business Mailing Address Fax Number:
208-287-2010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 W STATE ST
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-4038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-287-1110
Provider Business Practice Location Address Fax Number:
208-287-2010
Provider Enumeration Date:
06/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RENDON
Authorized Official First Name:
LISA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
M.D./OWNER
Authorized Official Telephone Number:
208-287-1110

Provider Taxonomy Codes

  • Taxonomy code: 207XS0106X , with the licence number:  M9105 , 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)