1013219310 NPI number — WESTERN IDAHO CENTER FOR SLEEP, 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 1013219310 NPI number — WESTERN IDAHO CENTER FOR SLEEP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN IDAHO CENTER FOR SLEEP, 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:
1013219310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1673 W SHORELINE DR
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83702-6750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-342-9800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 E HERSEY ST
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97520-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-488-7715
Provider Business Practice Location Address Fax Number:
541-488-7721
Provider Enumeration Date:
11/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
NOLES
Authorized Official First Name:
DODIE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
541-488-7715

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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