Provider Demographics
NPI:1164461042
Name:BOISE VAMC
Entity Type:Organization
Organization Name:BOISE VAMC
Other - Org Name:TWIN FALLS VA CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:NPI TEAM MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-382-2579
Mailing Address - Street 1:PO BOX 94402
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-4402
Mailing Address - Country:US
Mailing Address - Phone:702-341-3164
Mailing Address - Fax:
Practice Address - Street 1:260 2ND AVE E
Practice Address - Street 2:SUITE 12
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6242
Practice Address - Country:US
Practice Address - Phone:702-341-3164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA