=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144646126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEM CELL CENTERS OF IDAHO PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2014
-----------------------------------------------------
Last Update Date | 06/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1341 N NORTHWOOD CENTER CT STE B
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-2471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-771-7054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 W IRONWOOD DR
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-2651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-215-3261
-----------------------------------------------------
Fax | 208-966-4284
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | EMILY AUTOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-808-0708
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------