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General NPI Number Information
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NPI Number | 1407273147
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Entity Type | Organization
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Legal Business Name | IDAHO CENTER FOR REGENERATIVE MEDICINE
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Dates
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Enumeration Date | 03/19/2014
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Last Update Date | 03/17/2016
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Provider Practice Location Address
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Address Line | 868 E RIVERSIDE DR SUITE 170
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City | EAGLE
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State | ID
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Zip | 83616-5412
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Country | US
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Telephone | 208-995-2802
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Fax | 208-995-2804
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Provider Business Mailing Address
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Address Line | 868 E RIVERSIDE DR SUITE 170
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City | EAGLE
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State | ID
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Zip | 83616-5412
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Country | US
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Telephone | 208-995-2802
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Fax | 208-995-2804
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. ROBERT J HAAKE
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Credential | D.O.
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Telephone | 208-995-2802
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 207R00000X
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License Number State | ID
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