Provider Demographics
NPI:1063970143
Name:IDAHO STREET MEDICAL CLINIC
Entity type:Organization
Organization Name:IDAHO STREET MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROE
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:208-859-4103
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:HOMEDALE
Mailing Address - State:ID
Mailing Address - Zip Code:83628-0037
Mailing Address - Country:US
Mailing Address - Phone:208-337-3898
Mailing Address - Fax:
Practice Address - Street 1:126 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:208-859-4103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health