Provider Demographics
NPI:1063928638
Name:HNI MEDICAL SERVICES OF IDAHO, LLC
Entity type:Organization
Organization Name:HNI MEDICAL SERVICES OF IDAHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-727-3530
Mailing Address - Street 1:7500 RIALTO BLVD STE 1-140
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8534
Mailing Address - Country:US
Mailing Address - Phone:512-730-3056
Mailing Address - Fax:888-730-1925
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:512-730-3056
Practice Address - Fax:888-730-1925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1063928638Medicaid