=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104220797
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOISE SKIN CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2014
-----------------------------------------------------
Last Update Date | 01/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1636 S HADLEY AVE
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-2684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-209-7898
-----------------------------------------------------
Fax | 208-258-2079
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1636 S HADLEY AVE
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-2684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-209-7898
-----------------------------------------------------
Fax | 208-258-2079
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MARNIE R RIRIE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 208-258-2078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | M-9342
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------