Provider Demographics
NPI:1184640591
Name:IDALIS INC
Entity Type:Organization
Organization Name:IDALIS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:COOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:360-413-1728
Mailing Address - Street 1:3663 COLLEGE ST SE STE A
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-3529
Mailing Address - Country:US
Mailing Address - Phone:360-413-1728
Mailing Address - Fax:360-413-1669
Practice Address - Street 1:3663 COLLEGE ST SE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-3529
Practice Address - Country:US
Practice Address - Phone:360-413-1728
Practice Address - Fax:360-413-1669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA06-000278202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty