Organization Name: | EVENING MEDICAL CLINIC |
NPI Number: | 1043412133 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | MICHAEL P KLETT (OWNER) |
Mailing Address: | 1252 Bennett Ave Suite B Burley |
State: | ID US |
Postal Code: | 83318 |
Phone Number: | 2088783486 |
Fax Number: | 2088782005 |
NPI Enumeration Date: | 06/01/2007 |
NPI Last Update Date: | 07/16/2010 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QH0100X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Health Service |
Taxonomy Definition: |