1649220385 NPI number — ST LUKES FAMILY HEALTH, LLC

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 1649220385 NPI number — ST LUKES FAMILY HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LUKES FAMILY HEALTH, LLC
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:
1649220385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3090 E GENTRY WAY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-3501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-887-4606
Provider Business Mailing Address Fax Number:
208-887-0810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3090 E GENTRY WAY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-887-4606
Provider Business Practice Location Address Fax Number:
208-887-0810
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT ADMINISTRATOR
Authorized Official Telephone Number:
208-887-4606

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com