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General NPI Number Information
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NPI Number | 1073909016
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Entity Type | Organization
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Legal Business Name | DRUG TEST OF IDAHO LLC
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Dates
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Enumeration Date | 04/07/2015
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Last Update Date | 04/07/2015
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Provider Practice Location Address
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Address Line | 921 S ORCHARD ST STE A
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City | BOISE
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State | ID
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Zip | 83705-1992
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Country | US
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Telephone | 208-429-1445
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Fax | 208-429-1705
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Provider Business Mailing Address
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Address Line | 921 S ORCHARD ST STE A
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City | BOISE
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State | ID
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Zip | 83705-1992
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Country | US
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Telephone | 208-429-1445
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Fax | 208-429-1705
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Authorized Official
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Title or Position | OWNER
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Name | MR. DARRELL WICKHAM
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Credential |
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Telephone | 208-429-1445
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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