Provider Demographics
NPI:1265714760
Name:COMMUNITY CARE POCATELLO PLLC
Entity type:Organization
Organization Name:COMMUNITY CARE POCATELLO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-233-0032
Mailing Address - Street 1:1595 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4203
Mailing Address - Country:US
Mailing Address - Phone:208-233-0032
Mailing Address - Fax:208-237-9171
Practice Address - Street 1:1595 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4203
Practice Address - Country:US
Practice Address - Phone:208-233-0032
Practice Address - Fax:208-237-9171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care