1184881153 NPI number — POWDER BASIN ASSOCIATES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184881153 NPI number — POWDER BASIN ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POWDER BASIN ASSOCIATES
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:
1184881153
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7905 N MEADOWLARK WAY
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83815-5041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-209-0535
Provider Business Mailing Address Fax Number:
208-209-0966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 OREGON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELLOGG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83837-5008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-783-0427
Provider Business Practice Location Address Fax Number:
208-783-1387
Provider Enumeration Date:
05/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
208-209-0535

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 807277200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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