Provider Demographics
NPI:1558452268
Name:CLEARWATER MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:CLEARWATER MEDICAL CENTER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CELSO
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-743-8416
Mailing Address - Street 1:1522 17TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3652
Mailing Address - Country:US
Mailing Address - Phone:208-743-8416
Mailing Address - Fax:208-743-4642
Practice Address - Street 1:1522 17TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3652
Practice Address - Country:US
Practice Address - Phone:208-743-8416
Practice Address - Fax:208-743-4642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDA87025207Q00000X
IDNP740A363LF0000X
IDNP751A363LF0000X
IDNP372A363LF0000X
IDNP388A363LF0000X
IDNP390A363LF0000X
NP361A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0466670001Medicare NSC
ID1372186Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER