Healthcare Provider Details

I. General information

NPI: 1093576092
Provider Name (Legal Business Name): NORTHWEST CLINICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 PINE ST STE 9
POTLATCH ID
83855-9700
US

IV. Provider business mailing address

535 PINE ST STE 9
POTLATCH ID
83855-9700
US

V. Phone/Fax

Practice location:
  • Phone: 208-875-1212
  • Fax:
Mailing address:
  • Phone: 208-875-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WIL EDWARDS
Title or Position: OWNER
Credential: PHARMD
Phone: 208-875-1212