1235598137 NPI number — BOUNDARY COUNTY COMMUNITY RESTORIUM

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 1235598137 NPI number — BOUNDARY COUNTY COMMUNITY RESTORIUM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOUNDARY COUNTY COMMUNITY RESTORIUM
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:
1235598137
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6619 KANIKSU ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONNERS FERRY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83805-7532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-267-2453
Provider Business Mailing Address Fax Number:
208-267-7823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6619 KANIKSU ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONNERS FERRY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83805-7532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-267-2453
Provider Business Practice Location Address Fax Number:
208-267-7823
Provider Enumeration Date:
02/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MAGEE
Authorized Official First Name:
KARLENE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
208-267-2453

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  RC-118 , 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: A0000437 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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