Healthcare Provider Details

I. General information

NPI: 1063667319
Provider Name (Legal Business Name): MARYLIN EACKER LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2008
Last Update Date: 11/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N LINCOLN AVE
JEROME ID
83338-1853
US

IV. Provider business mailing address

728 EASTLAND DR N
TWIN FALLS ID
83301-4310
US

V. Phone/Fax

Practice location:
  • Phone: 208-731-5750
  • Fax:
Mailing address:
  • Phone: 208-731-5750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW 1427
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: