=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639117153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOISE DERMAESTHETICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2006
-----------------------------------------------------
Last Update Date | 09/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6126 W EMERALD ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-8857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-323-6525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6126 W EMERALD ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-8857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-323-6525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANGER
-----------------------------------------------------
Name | CHERYL D LUNDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-452-6794
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------