| Organization Name: | PAYETTE LAKES MEDICAL CLINIC, PA |
| NPI Number: | 1902937196 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JACQUELINE R BRUNS (VP - PHYSICIAN SERVICES) |
| Mailing Address: | 454 Rosebury Road Suite 103 Donnelly |
| State: | ID US |
| Postal Code: | 83615 |
| Phone Number: | 2083254455 |
| Fax Number: | 2083254466 |
| NPI Enumeration Date: | 03/08/2007 |
| NPI Last Update Date: | 03/17/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |