Healthcare Provider Details

I. General information

NPI: 1932392933
Provider Name (Legal Business Name): TIMBERLAKE FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 E HIGHWAY 54 STE A
ATHOL ID
83801-8255
US

IV. Provider business mailing address

PO BOX 775
ATHOL ID
83801-0775
US

V. Phone/Fax

Practice location:
  • Phone: 208-683-0800
  • Fax: 208-683-0900
Mailing address:
  • Phone: 208-683-0800
  • Fax: 208-683-0900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberPA303
License Number StateID

VIII. Authorized Official

Name: MR. CHRISTOPHER RAY SUNDQUIST
Title or Position: OWNER
Credential: PA-C
Phone: 208-683-0800