=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700828241
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA L HOUSE DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2006
-----------------------------------------------------
Last Update Date | 10/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5601 W CHINDEN BLVD
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83714-1463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-809-2865
-----------------------------------------------------
Fax | 208-809-2866
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 191050 SUITE 250
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83719-1050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-985-1399
-----------------------------------------------------
Fax | 208-955-6501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | O0370
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0-0370
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------