Healthcare Provider Details

I. General information

NPI: 1568700128
Provider Name (Legal Business Name): FAMILY CARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2013
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8050 W RIFLEMAN ST STE 100
BOISE ID
83704-9006
US

IV. Provider business mailing address

8050 W RIFLEMAN ST STE 100
BOISE ID
83704-9006
US

V. Phone/Fax

Practice location:
  • Phone: 208-321-0634
  • Fax: 208-321-1082
Mailing address:
  • Phone: 208-321-0634
  • Fax: 208-321-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURIE MILLER
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-321-0634