Healthcare Provider Details

I. General information

NPI: 1255608238
Provider Name (Legal Business Name): EAST BOISE COUNTY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2011
Last Update Date: 11/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3852 HIGHWAY 21
BOISE ID
83716
US

IV. Provider business mailing address

3852 HIGHWAY 21
BOISE ID
83716
US

V. Phone/Fax

Practice location:
  • Phone: 208-392-4544
  • Fax: 208-392-4128
Mailing address:
  • Phone: 208-392-4544
  • Fax: 208-392-4128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateID

VIII. Authorized Official

Name: LYNDA JOANNE MARICLE-KUWAHARA
Title or Position: EXECUTIVE DIRECTOR
Credential: APRN-C
Phone: 208-392-4544