Organization Name: | PAYETTE LAKES MEDICAL CLINIC, PA |
NPI Number: | 1922139468 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | JACQUELINE R BRUNS (VP - PHYSICIAN SERVICES) |
Mailing Address: | 320 Virginia Avenue New Meadows |
State: | ID US |
Postal Code: | 83654 |
Phone Number: | 2083472146 |
Fax Number: | 2083472147 |
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: |