Healthcare Provider Details

I. General information

NPI: 1144341637
Provider Name (Legal Business Name): THE PEDIATRIC AND ADOLESCENT CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6148 N DISCOVERY WAY SUITE 100
BOISE ID
83713-0201
US

IV. Provider business mailing address

6148 N DISCOVERY WAY SUITE 100
BOISE ID
83713-0201
US

V. Phone/Fax

Practice location:
  • Phone: 208-322-5437
  • Fax: 208-322-6013
Mailing address:
  • Phone: 208-322-5437
  • Fax: 208-322-6013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberM-5223
License Number StateID

VIII. Authorized Official

Name: WILLIAM SULLIVAN BOURQUARD
Title or Position: OWNER
Credential: M.D
Phone: 208-322-5437