1023287828 NPI number — POCATELLO CHILDREN'S CLINIC

Table of content: (NPI 1023287828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023287828 NPI number — POCATELLO CHILDREN'S CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POCATELLO CHILDREN'S CLINIC
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:
1023287828
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4730
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83205-4730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-232-1443
Provider Business Mailing Address Fax Number:
208-239-3434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 S 11TH AVE
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-4835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-1443
Provider Business Practice Location Address Fax Number:
208-239-3434
Provider Enumeration Date:
02/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PERRY
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
208-236-9600

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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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