Healthcare Provider Details

I. General information

NPI: 1558026302
Provider Name (Legal Business Name): SUNSHINE TELEMEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 JEFFERSON AVE
POCATELLO ID
83201-3625
US

IV. Provider business mailing address

805 JEFFERSON AVE
POCATELLO ID
83201-3625
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-0400
  • Fax: 208-238-0401
Mailing address:
  • Phone: 208-238-0400
  • Fax: 208-238-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. NATALIE ANN JOHNSON
Title or Position: MANAGER
Credential:
Phone: 208-313-2273