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General NPI Number Information
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NPI Number | 1114923471
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Entity Type | Organization
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Legal Business Name | SURGICARE CENTER OF IDAHO, LLC
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Dates
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Enumeration Date | 06/22/2005
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Last Update Date | 10/10/2016
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Provider Practice Location Address
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Address Line | 360 E MALLARD DR STE 125
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City | BOISE
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State | ID
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Zip | 83706-3941
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Country | US
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Telephone | 208-336-8700
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Fax | 208-426-0902
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Provider Business Mailing Address
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Address Line | 360 E MALLARD DR STE 125
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City | BOISE
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State | ID
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Zip | 83706-6644
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Country | US
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Telephone | 208-336-8700
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Fax | 208-426-0902
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. LOUIS PENNOW
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Credential | MBA
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Telephone | 208-336-8700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0132X
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Taxonomy Name | Ophthalmologic Surgery Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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