Healthcare Provider Details

I. General information

NPI: 1194058891
Provider Name (Legal Business Name): MICHAEL K SEELYE ST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2009
Last Update Date: 09/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 S MAIN ST STE 6
MOSCOW ID
83843-2983
US

IV. Provider business mailing address

623 S MAIN ST STE 6
MOSCOW ID
83843-2983
US

V. Phone/Fax

Practice location:
  • Phone: 208-883-2828
  • Fax: 208-882-2179
Mailing address:
  • Phone: 208-883-2828
  • Fax: 208-882-2179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberST6002086
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: