1790609477 NPI number — GEN STATE INTEGRATIVE MEDICINE

Table of content: (NPI 1790609477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790609477 NPI number — GEN STATE INTEGRATIVE MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEN STATE INTEGRATIVE MEDICINE
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:
1790609477
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 EAST HERITAGE PARK LANE, SUITE 150
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-202-7247
Provider Business Mailing Address Fax Number:
208-202-7246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 EAST HERITAGE PARK LANE, SUITE 150
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-202-7247
Provider Business Practice Location Address Fax Number:
208-202-7246
Provider Enumeration Date:
08/06/2026

Additional Information

Authorized Official

Authorized Official Last Name:
PETRIE
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
LYN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
208-365-7131

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2026 www.npivalidator.com