Healthcare Provider Details

I. General information

NPI: 1245613967
Provider Name (Legal Business Name): ID PHS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 W. BANNCOCK STREET STE 1100
BOISE ID
83702-6140
US

IV. Provider business mailing address

1509 DULLES DR
LAFAYETTE LA
70506-3718
US

V. Phone/Fax

Practice location:
  • Phone: 337-991-9276
  • Fax: 337-991-9288
Mailing address:
  • Phone: 337-991-9276
  • Fax: 337-991-9288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NICOLE HOWARD
Title or Position: CEO
Credential:
Phone: 337-991-9276