Healthcare Provider Details

I. General information

NPI: 1144382797
Provider Name (Legal Business Name): NORTH END CHILDREN'S HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 W FAIRVIEW AVE STE 206
BOISE ID
83702-5190
US

IV. Provider business mailing address

1655 W FAIRVIEW AVE STE 206
BOISE ID
83702-5190
US

V. Phone/Fax

Practice location:
  • Phone: 208-395-0000
  • Fax: 208-395-0009
Mailing address:
  • Phone: 208-395-0000
  • Fax: 208-395-0009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LEONA JO'ANNE' CHURCH
Title or Position: PRESIDENT, BOARD OF DIRECTORS
Credential: CPNP
Phone: 208-395-0000