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General NPI Number Information
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NPI Number | 1073601233
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Entity Type | Organization
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Legal Business Name | PHYSICIANS CLINIC PLLC
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4750 N FIVE MILE RD
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City | BOISE
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State | ID
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Zip | 83713-2715
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Country | US
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Telephone | 208-375-0500
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Fax | 208-375-4310
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Provider Business Mailing Address
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Address Line | 4750 N FIVE MILE RD
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City | BOISE
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State | ID
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Zip | 83713-2715
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Country | US
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Telephone | 208-375-0500
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Fax | 208-375-4310
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. CORINNE K CHASTAIN
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Credential |
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Telephone | 208-375-0500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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