Provider Demographics
NPI:1407273147
Name:IDAHO CENTER FOR REGENERATIVE MEDICINE
Entity Type:Organization
Organization Name:IDAHO CENTER FOR REGENERATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-995-2802
Mailing Address - Street 1:868 E RIVERSIDE DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5412
Mailing Address - Country:US
Mailing Address - Phone:208-995-2802
Mailing Address - Fax:208-995-2804
Practice Address - Street 1:868 E RIVERSIDE DR
Practice Address - Street 2:SUITE 170
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5412
Practice Address - Country:US
Practice Address - Phone:208-995-2802
Practice Address - Fax:208-995-2804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207R00000X207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty