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General NPI Number Information
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NPI Number | 1447880570
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Entity Type | Organization
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Legal Business Name | BORE LLC
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Dates
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Enumeration Date | 01/16/2020
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Last Update Date | 01/16/2020
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Provider Practice Location Address
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Address Line | 1498 MIDWAY AVE STE 2
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City | AMMON
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State | ID
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Zip | 83406-4587
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Country | US
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Telephone | 208-529-9930
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Fax |
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Provider Business Mailing Address
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Address Line | 1498 MIDWAY AVE STE 2
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City | AMMON
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State | ID
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Zip | 83406-4587
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CONTRACTING
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Name | HEATHER FUMICH
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Credential |
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Telephone | 503-502-0655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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