Provider Demographics
NPI:1043927882
Name:CORE MEDICINE IDAHO, LLC
Entity Type:Organization
Organization Name:CORE MEDICINE IDAHO, LLC
Other - Org Name:CORE MEDICINE OF IDAHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANANGER
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-795-5090
Mailing Address - Street 1:2667 E GALA CT STE 130
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2788
Mailing Address - Country:US
Mailing Address - Phone:208-795-5090
Mailing Address - Fax:
Practice Address - Street 1:4605 ENTERPRISE WAY
Practice Address - Street 2:STE 101
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-8360
Practice Address - Country:US
Practice Address - Phone:208-353-7518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-01
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1295734796Medicaid