1043927882 NPI number — CORE MEDICINE IDAHO, 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 1043927882 NPI number — CORE MEDICINE IDAHO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORE MEDICINE IDAHO, 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:
6
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:
1043927882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2667 E GALA CT STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-2788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-795-5090
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4605 ENTERPRISE WAY
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-8360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-353-7518
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2022

Additional Information

Authorized Official

Authorized Official Last Name:
RATH
Authorized Official First Name:
SOPHIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANANGER
Authorized Official Telephone Number:
208-795-5090

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1295734796 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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