Healthcare Provider Details

I. General information

NPI: 1114923471
Provider Name (Legal Business Name): SURGICARE CENTER OF IDAHO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E MALLARD DR STE 125
BOISE ID
83706-3941
US

IV. Provider business mailing address

360 E MALLARD DR STE 125
BOISE ID
83706-6644
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-8700
  • Fax: 208-426-0902
Mailing address:
  • Phone: 208-336-8700
  • Fax: 208-426-0902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LOUIS PENNOW
Title or Position: DIRECTOR
Credential: MBA
Phone: 208-336-8700