Healthcare Provider Details

I. General information

NPI: 1205556859
Provider Name (Legal Business Name): RURBAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 S OLIVE AVE
SANDPOINT ID
83864-1154
US

IV. Provider business mailing address

605 S OLIVE AVE
SANDPOINT ID
83864-1154
US

V. Phone/Fax

Practice location:
  • Phone: 208-899-9312
  • Fax:
Mailing address:
  • Phone: 208-899-9312
  • Fax: 208-686-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RIO PETERSONO PETERSON
Title or Position: FOUNDER/ CEO
Credential: PMHNP
Phone: 208-686-8060