Provider Demographics
NPI:1043412133
Name:EVENING MEDICAL CLINIC
Entity Type:Organization
Organization Name:EVENING MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:KLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-878-5255
Mailing Address - Street 1:1252 BENNETT AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318
Mailing Address - Country:US
Mailing Address - Phone:208-878-3486
Mailing Address - Fax:208-878-2005
Practice Address - Street 1:1252 BENNETT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318
Practice Address - Country:US
Practice Address - Phone:208-878-3486
Practice Address - Fax:208-878-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service