Provider Demographics
NPI:1194494229
Name:MANGUM PRIMARY CARE LLC
Entity type:Organization
Organization Name:MANGUM PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:801-793-8124
Mailing Address - Street 1:608 S PHILLIPPI ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1160
Mailing Address - Country:US
Mailing Address - Phone:801-793-8124
Mailing Address - Fax:
Practice Address - Street 1:3046 S BOWN WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-5499
Practice Address - Country:US
Practice Address - Phone:801-793-8124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-11
Last Update Date:2021-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care