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General NPI Number Information
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NPI Number | 1376083568
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Entity Type | Organization
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Legal Business Name | PATRIOT HEALTHCARE, LLC
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Dates
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Enumeration Date | 03/07/2017
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Last Update Date | 03/07/2017
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Provider Practice Location Address
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Address Line | 144 OASIS DR
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City | POCATELLO
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State | ID
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Zip | 83204-4826
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Country | US
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Telephone | 208-541-0920
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Fax |
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Provider Business Mailing Address
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Address Line | 144 OASIS DR
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City | POCATELLO
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State | ID
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Zip | 83204-4826
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Country | US
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Telephone | 208-541-0920
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR/CEO
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Name | MR. KENNETH RAY LOWTHER
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Credential | FNP-C
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Telephone | 208-541-0920
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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