Provider Demographics
NPI:1528125176
Name:SALMON RIVER CLINIC HOSPITAL DISTRICT
Entity type:Organization
Organization Name:SALMON RIVER CLINIC HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MERCANTINI
Authorized Official - Last Name:KLINGLER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-774-3565
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83278-0129
Mailing Address - Country:US
Mailing Address - Phone:208-774-3565
Mailing Address - Fax:208-774-3424
Practice Address - Street 1:1 NIECE AVENUE
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:ID
Practice Address - Zip Code:83278-0129
Practice Address - Country:US
Practice Address - Phone:208-774-3565
Practice Address - Fax:208-774-3424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55103416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010006657OtherBS
IDE0815OtherBLUE CROSS
ID002504200Medicaid
ID002504200Medicaid