Provider Demographics
NPI:1184865883
Name:OPTIMAL HEATLH MEDICAL INSTITURE
Entity Type:Organization
Organization Name:OPTIMAL HEATLH MEDICAL INSTITURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:SUTHERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-495-3688
Mailing Address - Street 1:3224 N MAPLE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4214
Mailing Address - Country:US
Mailing Address - Phone:208-495-3688
Mailing Address - Fax:208-475-4924
Practice Address - Street 1:3224 N MAPLE GROVE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4214
Practice Address - Country:US
Practice Address - Phone:208-495-3688
Practice Address - Fax:208-475-4924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-2642083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S62890Medicare UPIN
IDF41471Medicare UPIN