1366601734 NPI number — TMD PLLC

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 1366601734 NPI number — TMD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TMD PLLC
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:
1366601734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2031 E HOSPITALITY LN
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83716-6603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-333-9999
Provider Business Mailing Address Fax Number:
208-343-5889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2031 E HOSPITALITY LN
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83716-6603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-333-9999
Provider Business Practice Location Address Fax Number:
208-343-5889
Provider Enumeration Date:
06/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RYAN
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
208-333-9999

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D3273 , 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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