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General NPI Number Information
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NPI Number | 1245690544
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Entity Type | Organization
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Legal Business Name | OLDE TOWN MEDICAL
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Dates
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Enumeration Date | 02/29/2016
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Last Update Date | 03/11/2016
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Provider Practice Location Address
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Address Line | 124 E PINE AVE
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City | MERIDIAN
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State | ID
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Zip | 83642-2331
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Country | US
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Telephone | 208-887-5422
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Fax | 208-888-6297
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Provider Business Mailing Address
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Address Line | 124 E PINE AVE
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City | MERIDIAN
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State | ID
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Zip | 83642-2331
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Country | US
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Telephone | 208-887-5422
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Fax | 208-888-6297
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Authorized Official
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Title or Position | PROVIDER/OWNER
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Name | SUSAN E TOMEY
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Credential | NP
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Telephone | 208-888-5422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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