Healthcare Provider Details

I. General information

NPI: 1043927882
Provider Name (Legal Business Name): CORE MEDICINE IDAHO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 ENTERPRISE WAY STE 101
CALDWELL ID
83605-8360
US

IV. Provider business mailing address

2667 E GALA CT STE 130
MERIDIAN ID
83642-2788
US

V. Phone/Fax

Practice location:
  • Phone: 208-353-7518
  • Fax:
Mailing address:
  • Phone: 208-795-5090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SOPHIE RATH
Title or Position: MANANGER
Credential:
Phone: 208-795-5090