Provider Demographics
NPI:1306010046
Name:PEINE OSTEOPATHIC MEDICINE PLLC
Entity Type:Organization
Organization Name:PEINE OSTEOPATHIC MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:C
Authorized Official - Last Name:PEINE
Authorized Official - Suffix:
Authorized Official - Credentials:D,O,
Authorized Official - Phone:208-947-0925
Mailing Address - Street 1:450 W STATE ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7057
Mailing Address - Country:US
Mailing Address - Phone:208-947-0925
Mailing Address - Fax:208-947-0926
Practice Address - Street 1:450 W STATE ST
Practice Address - Street 2:SUITE 250
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7057
Practice Address - Country:US
Practice Address - Phone:208-947-0925
Practice Address - Fax:208-947-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0366207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty