Healthcare Provider Details

I. General information

NPI: 1124152921
Provider Name (Legal Business Name): BOISE VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 HAYSTACK WAY
CALDWELL ID
83605-6981
US

IV. Provider business mailing address

PO BOX 94402
CLEVELAND OH
44101-4402
US

V. Phone/Fax

Practice location:
  • Phone: 702-341-3164
  • Fax:
Mailing address:
  • Phone: 702-341-3164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. ERIN POTTER
Title or Position: NPI TEAM MEMBER
Credential:
Phone: 202-382-2579