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General NPI Number Information
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NPI Number | 1649392200
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Entity Type | Organization
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Legal Business Name | FAMILY PRACTICE MEDICAL
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 777 N RAYMOND ST
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City | BOISE
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State | ID
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Zip | 83704-9251
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Country | US
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Telephone | 208-367-6030
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Fax |
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Provider Business Mailing Address
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Address Line | 6318 BERMUDA DR
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City | BOISE
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State | ID
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Zip | 83709-1009
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Country | US
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Telephone | 208-378-0070
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Fax |
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Authorized Official
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Title or Position | SOCIAL WORKER
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Name | MR. TOM C AHLRICHS
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Credential | LCSW
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Telephone | 208-367-6030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LCSW-24633
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License Number State | ID
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