Provider Demographics
NPI:1043835713
Name:IDAHO ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:IDAHO ENDOSCOPY CENTER LLC
Other - Org Name:NAMPA IDAHO ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-489-1900
Mailing Address - Street 1:6259 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8731
Mailing Address - Country:US
Mailing Address - Phone:208-489-1900
Mailing Address - Fax:208-489-1929
Practice Address - Street 1:5080 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5513
Practice Address - Country:US
Practice Address - Phone:986-867-1600
Practice Address - Fax:986-867-1601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO ENDOSCOPY CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-09
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical