MEDICARE: IDEAL TELEMEDICINE SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1669189148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL TELEMEDICINE SERVICES, LLC

Provider Business Mailing Address
First Line	:	5615 DUNBARTON AVE
Second Line	:
City	:	PASCO
State	:	WA
Zip	:	99301-8216
Country	:	US
Telephone Number	:	509-222-1275
Fax Number	:	833-888-7145

Provider Business Practice Location Address
First Line	:	301 SADDLE DR STE G
Second Line	:
City	:	HELENA
State	:	MT
Zip	:	59601-8026
Country	:	US
Telephone Number	:	877-522-1275
Fax Number	:	833-888-7145

Authorized Official
Title or Position	:	CONTRACTING & CREDENTIALING MANAGER
Name	:	SHANNON BOWDEN
Credential	:
Telephone Number	:	509-570-9602

Provider Enumeration Date	:	11/03/2022
Last Update Date	:	11/03/2022

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