Healthcare Provider Details

I. General information

NPI: 1649392200
Provider Name (Legal Business Name): FAMILY PRACTICE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N RAYMOND ST
BOISE ID
83704-9251
US

IV. Provider business mailing address

6318 BERMUDA DR
BOISE ID
83709-1009
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6030
  • Fax:
Mailing address:
  • Phone: 208-378-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW-24633
License Number StateID

VIII. Authorized Official

Name: MR. TOM C AHLRICHS
Title or Position: SOCIAL WORKER
Credential: LCSW
Phone: 208-367-6030