=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326009648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUBLIC HEALTH DISTRICT IV
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2006
-----------------------------------------------------
Last Update Date | 10/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 707 N ARMSTRONG PL
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-0825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-375-5211
-----------------------------------------------------
Fax | 208-327-8500
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 N ARMSTRONG PL
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-0825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-375-5211
-----------------------------------------------------
Fax | 208-327-8500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC MANAGER
-----------------------------------------------------
Name | SARAH MCMURTRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-327-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | N/A PUBLIC HEALTH AG
-----------------------------------------------------
License Number State |
-----------------------------------------------------