Healthcare Provider Details

I. General information

NPI: 1013237528
Provider Name (Legal Business Name): PEAK MEDICAL OF BOISE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 MONTANA STREET
GOODING ID
83330-1856
US

IV. Provider business mailing address

1220 MONTANA STREET
GOODING ID
83330-1856
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-5601
  • Fax: 208-934-8154
Mailing address:
  • Phone: 208-934-5601
  • Fax: 208-934-8154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752