1609563618 NPI number — FIRST CARE CONCUSSION DIAGNOSTIC CLINICS OF IDAHO, LLC

Table of content: (NPI 1609563618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609563618 NPI number — FIRST CARE CONCUSSION DIAGNOSTIC CLINICS OF IDAHO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRST CARE CONCUSSION DIAGNOSTIC CLINICS OF 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:
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:
1609563618
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1988 W 930 N STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLEASANT GROVE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84062-4132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-403-1103
Provider Business Mailing Address Fax Number:
385-365-5054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24641 BLAZE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83644-6156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-403-1103
Provider Business Practice Location Address Fax Number:
385-365-5054
Provider Enumeration Date:
04/19/2023

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
NATHAN
Authorized Official Middle Name:
DEE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
801-899-2053

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com