Healthcare Provider Details

I. General information

NPI: 1831065481
Provider Name (Legal Business Name): NEW AGE MED CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 10/13/2025
Certification Date: 10/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 W ELDER ST STE 102
BOISE ID
83705-4986
US

IV. Provider business mailing address

4320 W EDGEMONT ST
BOISE ID
83706-2304
US

V. Phone/Fax

Practice location:
  • Phone: 208-573-3053
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES DONNELLY
Title or Position: CO-OWNER
Credential:
Phone: 208-573-3053