Provider Demographics
NPI:1538578687
Name:URGENT CARE OF IDAHO, LLC
Entity type:Organization
Organization Name:URGENT CARE OF IDAHO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-678-6996
Mailing Address - Street 1:PO BOX 773
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-5483
Mailing Address - Country:US
Mailing Address - Phone:208-324-2004
Mailing Address - Fax:208-324-1154
Practice Address - Street 1:133 W AVENUE A
Practice Address - Street 2:SUITE B
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-2630
Practice Address - Country:US
Practice Address - Phone:208-324-2004
Practice Address - Fax:208-324-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-02
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-154207Q00000X
IDM-9766207Q00000X
ID261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13D2082421OtherCLIA
ID1538578687Medicaid