Provider Demographics
NPI:1316226814
Name:INTEGRATIVE MEDICINE OF LEWISTON
Entity Type:Organization
Organization Name:INTEGRATIVE MEDICINE OF LEWISTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-799-3333
Mailing Address - Street 1:3510 12TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5575
Mailing Address - Country:US
Mailing Address - Phone:208-799-3333
Mailing Address - Fax:208-799-3375
Practice Address - Street 1:3510 12TH ST STE 200
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5575
Practice Address - Country:US
Practice Address - Phone:208-799-3333
Practice Address - Fax:208-799-3375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1087A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty