Healthcare Provider Details

I. General information

NPI: 1053615427
Provider Name (Legal Business Name): FAMILY MEDICAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2010
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 W PRAIRIE SHOPPING CTR
HAYDEN ID
83835-9855
US

IV. Provider business mailing address

265 W PRAIRIE SHOPPING CTR
HAYDEN ID
83835-9855
US

V. Phone/Fax

Practice location:
  • Phone: 208-772-7850
  • Fax: 208-772-2313
Mailing address:
  • Phone: 208-772-7850
  • Fax: 208-772-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-7938
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAG-019
License Number StateID

VIII. Authorized Official

Name: DR. JOHN LAWRENCE TORQUATO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 208-772-7850