Provider Demographics
NPI:1962268938
Name:CENTRAL IDAHO INFUSION CENTER
Entity type:Organization
Organization Name:CENTRAL IDAHO INFUSION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOLYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:208-316-6424
Mailing Address - Street 1:1115 8TH AVE E
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-2139
Mailing Address - Country:US
Mailing Address - Phone:208-316-6424
Mailing Address - Fax:
Practice Address - Street 1:868 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-2446
Practice Address - Country:US
Practice Address - Phone:208-316-6424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service