1093245953 NPI number — EMP IDAHO NAMPA, LLC

Table of content: (NPI 1093245953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093245953 NPI number — EMP IDAHO NAMPA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMP IDAHO NAMPA, 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:
1093245953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8686 NEW TRAILS DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THE WOODLANDS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77381-1176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-637-1146
Provider Business Mailing Address Fax Number:
281-298-5311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 12TH AVENUE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-637-1146
Provider Business Practice Location Address Fax Number:
281-298-5311
Provider Enumeration Date:
06/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BUCK
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
713-637-1004

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  71 , 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)

  • Identifier: 1093245953 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13-0072 . This is a "MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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