Healthcare Provider Details

I. General information

NPI: 1457696551
Provider Name (Legal Business Name): NORTH IDAHO COLLEGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2012
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 N LAKEWOOD DR STE B
COEUR D ALENE ID
83814-2638
US

IV. Provider business mailing address

2120 N LAKEWOOD DR STE B
COEUR D ALENE ID
83814-2638
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-3179
  • Fax: 208-667-5938
Mailing address:
  • Phone: 208-667-3179
  • Fax: 208-667-5938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: PEARL BOUCHARD
Title or Position: DIRECTOR
Credential:
Phone: 208-667-3179