Provider Demographics
NPI:1114600277
Name:IDAHORMONES
Entity Type:Organization
Organization Name:IDAHORMONES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:208-874-2394
Mailing Address - Street 1:4954 W GREY TOWERS DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9281
Mailing Address - Country:US
Mailing Address - Phone:208-874-2394
Mailing Address - Fax:
Practice Address - Street 1:3648 N CENTREPOINT WAY STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7626
Practice Address - Country:US
Practice Address - Phone:208-874-2394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty