Provider Demographics
NPI:1154976983
Name:IDAHO EAR CLINIC LLC
Entity type:Organization
Organization Name:IDAHO EAR CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:V
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-938-5823
Mailing Address - Street 1:1209 N SUMMERBROOK AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8750
Mailing Address - Country:US
Mailing Address - Phone:208-938-5823
Mailing Address - Fax:208-938-5306
Practice Address - Street 1:1209 N SUMMERBROOK AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8749
Practice Address - Country:US
Practice Address - Phone:208-938-5823
Practice Address - Fax:208-938-5306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-08
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty