Healthcare Provider Details

I. General information

NPI: 1902937196
Provider Name (Legal Business Name): PAYETTE LAKES MEDICAL CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 ROSEBURY ROAD SUITE 103
DONNELLY ID
83615
US

IV. Provider business mailing address

PO BOX 1047
MCCALL ID
83638-1047
US

V. Phone/Fax

Practice location:
  • Phone: 208-325-4455
  • Fax: 208-325-4466
Mailing address:
  • Phone: 208-325-4455
  • Fax: 208-325-4466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE R BRUNS
Title or Position: VP - PHYSICIAN SERVICES
Credential:
Phone: 208-634-4061