Healthcare Provider Details

I. General information

NPI: 1780398586
Provider Name (Legal Business Name): SIPI CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 FALLS AVE
TWIN FALLS ID
83301-2306
US

IV. Provider business mailing address

176 FALLS AVE
TWIN FALLS ID
83301-2306
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-3181
  • Fax: 208-733-3168
Mailing address:
  • Phone: 208-733-3181
  • Fax: 208-733-3168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DENISE RUE
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-733-3181