Provider Demographics
NPI:1083937049
Name:EAGLE HEALTH AND WELLNESS, INC
Entity Type:Organization
Organization Name:EAGLE HEALTH AND WELLNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:ELSTUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-938-4040
Mailing Address - Street 1:3771 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5005
Mailing Address - Country:US
Mailing Address - Phone:208-938-4040
Mailing Address - Fax:208-938-4099
Practice Address - Street 1:3771 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5005
Practice Address - Country:US
Practice Address - Phone:208-938-4040
Practice Address - Fax:208-938-4099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-2918101Y00000X
IDCHIA-1198111N00000X
IDM-9150207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty