Healthcare Provider Details

I. General information

NPI: 1952654741
Provider Name (Legal Business Name): I CARE MEDICAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 N BRIDGE ST
SAINT ANTHONY ID
83445-1425
US

IV. Provider business mailing address

430 N BRIDGE ST
SAINT ANTHONY ID
83445-1425
US

V. Phone/Fax

Practice location:
  • Phone: 208-624-4402
  • Fax: 208-624-4409
Mailing address:
  • Phone: 208-624-4402
  • Fax: 208-624-4409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 519
License Number StateID

VIII. Authorized Official

Name: JENNIFER RICKELL WILLMORE
Title or Position: OWNER
Credential: MPAS, PAC
Phone: 208-624-4402