1164288619 NPI number — IDEA TELEMEDICINE SERVICES LLC

Table of content: (NPI 1164288619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164288619 NPI number — IDEA TELEMEDICINE SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDEA TELEMEDICINE SERVICES 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:
1164288619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5615 DUNBARTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASCO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99301-8216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-221-2758
Provider Business Mailing Address Fax Number:
509-491-3031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
390 HODGSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA FALLS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59912-9063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-522-1275
Provider Business Practice Location Address Fax Number:
509-491-3031
Provider Enumeration Date:
02/22/2024

Additional Information

Authorized Official

Authorized Official Last Name:
DAWSON
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
JEFFERSON
Authorized Official Title or Position:
CMO
Authorized Official Telephone Number:
509-222-1275

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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