Healthcare Provider Details

I. General information

NPI: 1619484102
Provider Name (Legal Business Name): ALIGN INTEGRATED MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W USTICK RD STE 100
MERIDIAN ID
83646
US

IV. Provider business mailing address

750 W USTICK RD STE 100
MERIDIAN ID
83646-6133
US

V. Phone/Fax

Practice location:
  • Phone: 208-639-1397
  • Fax:
Mailing address:
  • Phone: 208-639-1397
  • Fax:

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 Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: CHAD WOOLNER
Title or Position: CEO
Credential:
Phone: 208-639-1397