Provider Demographics
NPI:1861982456
Name:ST LUKES CLINIC - TREASURE VALLEY LLC
Entity type:Organization
Organization Name:ST LUKES CLINIC - TREASURE VALLEY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-381-2520
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:5155 S HOWRY LANE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-381-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. LUKE'S HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty