1881982510 NPI number — ST LUKES CLINIC - MCCALL LLC

Table of content: (NPI 1881982510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881982510 NPI number — ST LUKES CLINIC - MCCALL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LUKES CLINIC - MCCALL 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:
ST LUKES CLINIC - MCCALL
Provider Other Organization Name Type Code:
3
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:
1881982510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 640
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:
83701-0640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-381-2222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 STATE 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:
83638-3704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-634-2221
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FOWLER
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VP, CFO
Authorized Official Telephone Number:
208-381-8717

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  11 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 11 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 11 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 11 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 11 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 138516 . This is a "MEDICARE - RHC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 20001637 . This is a "MEDICARE - CLINIC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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