Healthcare Provider Details

I. General information

NPI: 1730165838
Provider Name (Legal Business Name): SOUTHERN IDAHO REGIONAL LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 01/06/2010
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

BOX 2693
SPOKANE WA
99220
US

V. Phone/Fax

Practice location:
  • Phone: 800-574-8854
  • Fax:
Mailing address:
  • Phone: 800-574-8854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. KURT ROGERS
Title or Position: CFO
Credential:
Phone: 509-755-8903