Provider Demographics
NPI:1023639622
Name:IDAHO STREET MEDICAL CLINIC
Entity type:Organization
Organization Name:IDAHO STREET MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:ROE
Authorized Official - Suffix:
Authorized Official - Credentials:NP-BC
Authorized Official - Phone:208-859-4103
Mailing Address - Street 1:24900 MARKET RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:ID
Mailing Address - Zip Code:83660-6723
Mailing Address - Country:US
Mailing Address - Phone:208-722-7744
Mailing Address - Fax:
Practice Address - Street 1:126 W. IDAHO AVE
Practice Address - Street 2:
Practice Address - City:HOMEDALE
Practice Address - State:ID
Practice Address - Zip Code:83628-8362
Practice Address - Country:US
Practice Address - Phone:208-337-7038
Practice Address - Fax:208-337-4652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service