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General NPI Number Information
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NPI Number | 1083937049
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Entity Type | Organization
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Legal Business Name | EAGLE HEALTH AND WELLNESS, INC
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Dates
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Enumeration Date | 03/04/2010
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Last Update Date | 03/04/2010
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Provider Practice Location Address
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Address Line | 3771 N EAGLE RD
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City | BOISE
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State | ID
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Zip | 83713-5005
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Country | US
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Telephone | 208-938-4040
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Fax | 208-938-4099
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Provider Business Mailing Address
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Address Line | 3771 N EAGLE RD
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City | BOISE
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State | ID
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Zip | 83713-5005
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Country | US
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Telephone | 208-938-4040
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Fax | 208-938-4099
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Authorized Official
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Title or Position | PRESIDENT AND MEDICAL DIRECTOR
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Name | DR. KATHERINE MICHELLE ELSTUN
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Credential | MD
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Telephone | 208-938-4040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | LCPC-2918
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIA-1198
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M-9150
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License Number State | ID
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