1417967696 NPI number — TREASURE VALLEY ENDOCRINOLOGY PC

Table of content: (NPI 1417967696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417967696 NPI number — TREASURE VALLEY ENDOCRINOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TREASURE VALLEY ENDOCRINOLOGY PC
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:
1417967696
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4143
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83711-4143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-367-6740
Provider Business Mailing Address Fax Number:
208-367-6742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 N LIBERTY ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-8707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-6740
Provider Business Practice Location Address Fax Number:
208-367-6742
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOOTE
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
ENDOCRINOLOGIST
Authorized Official Telephone Number:
208-367-6740

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  M 6551 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 807326100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com