Healthcare Provider Details

I. General information

NPI: 1467621383
Provider Name (Legal Business Name): NUTRITIONAL MEDICINE OF IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 W STATE ST SUITE 220
BOISE ID
83702-4085
US

IV. Provider business mailing address

1520 W STATE ST SUITE 220
BOISE ID
83702-4085
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-3883
  • Fax: 208-287-2010
Mailing address:
  • Phone: 208-343-3883
  • Fax: 208-287-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberD043
License Number StateID

VIII. Authorized Official

Name: DR. MATTHEW R MACHA
Title or Position: OWNER
Credential: M.D.
Phone: 208-343-3883