Provider Demographics
NPI:1245778208
Name:DIRECT ORTHOPEDIC CARE LLC
Entity Type:Organization
Organization Name:DIRECT ORTHOPEDIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-321-4000
Mailing Address - Street 1:7979 W RIFLEMAN ST
Mailing Address - Street 2:STE 110
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9066
Mailing Address - Country:US
Mailing Address - Phone:208-321-4000
Mailing Address - Fax:208-855-0157
Practice Address - Street 1:3015 E MAGIC VIEW DR
Practice Address - Street 2:STE 115
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3757
Practice Address - Country:US
Practice Address - Phone:208-321-4000
Practice Address - Fax:208-855-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20005078Medicare PIN