Healthcare Provider Details

I. General information

NPI: 1821459496
Provider Name (Legal Business Name): GEM STATE ENDOSCOPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3709 14TH STREET
LEWISTON ID
83501
US

IV. Provider business mailing address

2517 17TH ST STE B
LEWISTON ID
83501-6311
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-4373
  • Fax: 208-743-3369
Mailing address:
  • Phone: 208-743-4373
  • Fax: 208-743-3369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATIE BLEVINS
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-298-2135