Provider Demographics
NPI:1063585305
Name:IDAHO SLEEP AND NEUROLOGY PLLC
Entity type:Organization
Organization Name:IDAHO SLEEP AND NEUROLOGY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-454-0567
Mailing Address - Street 1:211 E LOGAN ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4882
Mailing Address - Country:US
Mailing Address - Phone:208-454-0567
Mailing Address - Fax:208-454-0965
Practice Address - Street 1:211 E LOGAN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4882
Practice Address - Country:US
Practice Address - Phone:208-454-0567
Practice Address - Fax:208-454-0965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID=========OtherFEDERAL TAX I.D. NUMBER
ID=========OtherFEDERAL TAX I.D. NUMBER