1316556277 NPI number — CARISSA ELLEN CHAMBERLAIN CPM, LM

Table of content: CARISSA ELLEN CHAMBERLAIN CPM, LM (NPI 1316556277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316556277 NPI number — CARISSA ELLEN CHAMBERLAIN CPM, LM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAMBERLAIN
Provider First Name:
CARISSA
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPM, LM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
CARISSA
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316556277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 BOYDSTUN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCALL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83638-3403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-615-2273
Provider Business Mailing Address Fax Number:
208-630-6303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 BOYDSTUN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCCALL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83638-3403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-615-2273
Provider Business Practice Location Address Fax Number:
208-630-6303
Provider Enumeration Date:
07/27/2020

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: 176B00000X , with the licence number:  MID-105 , 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)





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