=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164397410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT MEDICAL PROVIDERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2025
-----------------------------------------------------
Last Update Date | 10/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2205 E RIVERSIDE DR
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-7620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-867-9760
-----------------------------------------------------
Fax | 801-880-4400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2205 E RIVERSIDE DR
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-7620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-867-9760
-----------------------------------------------------
Fax | 801-880-4400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RACHEL FLETCHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-867-9760
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------