Provider Demographics
NPI:1003208638
Name:SCHMADEKA, VICKEY
Entity Type:Individual
Prefix:
First Name:VICKEY
Middle Name:
Last Name:SCHMADEKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8565 W STONEHAVEN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7079
Mailing Address - Country:US
Mailing Address - Phone:541-805-0028
Mailing Address - Fax:
Practice Address - Street 1:8565 W STONEHAVEN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7079
Practice Address - Country:US
Practice Address - Phone:541-805-0028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-2130171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor