Provider Demographics
NPI:1336656040
Name:FUNCTIONAL MEDICINE OF IDAHO PC
Entity Type:Organization
Organization Name:FUNCTIONAL MEDICINE OF IDAHO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-385-7711
Mailing Address - Street 1:3858 N GARDEN CENTER WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5008
Mailing Address - Country:US
Mailing Address - Phone:208-385-7711
Mailing Address - Fax:208-385-0346
Practice Address - Street 1:3858 N GARDEN CENTER WAY STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5008
Practice Address - Country:US
Practice Address - Phone:208-385-7711
Practice Address - Fax:208-385-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty