Healthcare Provider Details

I. General information

NPI: 1306807441
Provider Name (Legal Business Name): CLINIC AT EAGLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E STATE ST SUITE 200
EAGLE ID
83616-6081
US

IV. Provider business mailing address

PO BOX 9589
BOISE ID
83707-4589
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-2237
  • Fax: 208-939-5888
Mailing address:
  • Phone: 208-472-8112
  • Fax: 208-472-8172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHE ALKIRE
Title or Position: OWNER
Credential: CRNP
Phone: 208-939-2273