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General NPI Number Information
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NPI Number | 1841444015
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Entity Type | Organization
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Legal Business Name | 1ST CLINIC
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Dates
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Enumeration Date | 11/13/2008
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Last Update Date | 11/13/2008
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Provider Practice Location Address
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Address Line | 265 W PRAIRIE SHOPPING CTR
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City | HAYDEN
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State | ID
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Zip | 83835-9855
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Country | US
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Telephone | 208-772-7850
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Fax | 208-772-2313
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Provider Business Mailing Address
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Address Line | 265 W PRAIRIE SHOPPING CTR
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City | HAYDEN
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State | ID
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Zip | 83835-9855
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Country | US
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Telephone | 208-772-7850
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Fax | 208-772-2313
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Authorized Official
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Title or Position | CONTRACT PHYSICIAN
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Name | DR. JOHN L. TORQUATO
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Credential | MD
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Telephone | 208-772-7850
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | C158693 INC.STATEID
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License Number State | ID
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