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General NPI Number Information
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NPI Number | 1194494229
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Entity Type | Organization
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Legal Business Name | MANGUM PRIMARY CARE LLC
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Dates
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Enumeration Date | 09/11/2021
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Last Update Date | 09/11/2021
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Provider Practice Location Address
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Address Line | 3046 S BOWN WAY
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City | BOISE
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State | ID
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Zip | 83706-5499
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Country | US
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Telephone | 801-793-8124
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Fax |
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Provider Business Mailing Address
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Address Line | 608 S PHILLIPPI ST
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City | BOISE
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State | ID
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Zip | 83705-1160
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Country | US
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Telephone | 801-793-8124
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MEREDITH KAYE MANGUM
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Credential | FNP-C
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Telephone | 801-793-8124
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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