1740251925 NPI number — ADA BOI INC

Table of content: (NPI 1740251925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740251925 NPI number — ADA BOI INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADA BOI INC
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:
1740251925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 190480
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83719-0480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-362-2973
Provider Business Mailing Address Fax Number:
208-362-0854

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7701 W MOSSY CUP ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83709-2844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-362-2973
Provider Business Practice Location Address Fax Number:
208-362-0854
Provider Enumeration Date:
01/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOGG
Authorized Official First Name:
KATHIE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
208-362-2973

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  8405 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3416L0300X , with the licence number: 8405 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000010014479 . This is a "BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002496600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: E0419 . This is a "TRUE BLUE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: E0419 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 590157443 . This is a "RR MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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