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General NPI Number Information
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NPI Number | 1821459496
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Entity Type | Organization
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Legal Business Name | GEM STATE ENDOSCOPY
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Dates
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Enumeration Date | 03/10/2016
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Last Update Date | 08/09/2016
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Provider Practice Location Address
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Address Line | 3709 14TH STREET
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City | LEWISTON
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State | ID
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Zip | 83501
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Country | US
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Telephone | 208-743-4373
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Fax | 208-743-3369
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Provider Business Mailing Address
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Address Line | 2517 17TH ST STE B
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City | LEWISTON
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State | ID
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Zip | 83501-6311
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Country | US
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Telephone | 208-743-4373
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Fax | 208-743-3369
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KATIE BLEVINS
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Credential |
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Telephone | 208-298-2135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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