MEDICARE: CLINIC AT EAGLE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000010135253	OTHER	ID	BLUE SHIELD
2	8G171	OTHER	ID	BLUE CROSS

General Provider Information

NPI Number	:	1306807441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINIC AT EAGLE LLC

Provider Business Mailing Address
First Line	:	PO BOX 9589
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83707-4589
Country	:	US
Telephone Number	:	208-472-8112
Fax Number	:	208-472-8172

Provider Business Practice Location Address
First Line	:	600 E STATE ST
Second Line	:	SUITE 200
City	:	EAGLE
State	:	ID
Zip	:	83616-6081
Country	:	US
Telephone Number	:	208-939-2237
Fax Number	:	208-939-5888

Authorized Official
Title or Position	:	OWNER
Name	:	KATHE ALKIRE
Credential	:	CRNP
Telephone Number	:	208-939-2273

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	07/27/2010

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Directions to “CLINIC AT EAGLE LLC ” Practice Location

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