Provider Demographics
NPI:1306807441
Name:CLINIC AT EAGLE LLC
Entity type:Organization
Organization Name:CLINIC AT EAGLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALKIRE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:208-939-2273
Mailing Address - Street 1:PO BOX 9589
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-4589
Mailing Address - Country:US
Mailing Address - Phone:208-472-8112
Mailing Address - Fax:208-472-8172
Practice Address - Street 1:600 E STATE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6081
Practice Address - Country:US
Practice Address - Phone:208-939-2237
Practice Address - Fax:208-939-5888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010135253OtherBLUE SHIELD
ID8G171OtherBLUE CROSS
ID1374322Medicare PIN