Healthcare Provider Details

I. General information

NPI: 1629095179
Provider Name (Legal Business Name): ST ALPHONSUS PROFESSIONAL MEDICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 9589
BOISE ID
83707-4589
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-3131
  • Fax:
Mailing address:
  • Phone: 208-472-8115
  • Fax: 208-344-1926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD PRESNELL
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 208-367-2881