Healthcare Provider Details

I. General information

NPI: 1942730775
Provider Name (Legal Business Name): FAMILY MEDICAL CARE CLINICS CORPORATION A PROFESSIONAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 03/17/2018
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

PO BOX 38
HAYDEN ID
83835-0038
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 Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOHN L TORQUATO
Title or Position: PRESIDENT
Credential: MD
Phone: 208-772-7850