Provider Demographics
NPI:1417104530
Name:CENTER STREET HEALTH CARE LLC
Entity Type:Organization
Organization Name:CENTER STREET HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:RNCNP
Authorized Official - Phone:208-233-9355
Mailing Address - Street 1:1553 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4135
Mailing Address - Country:US
Mailing Address - Phone:208-233-9355
Mailing Address - Fax:208-233-9300
Practice Address - Street 1:1553 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4135
Practice Address - Country:US
Practice Address - Phone:208-233-9355
Practice Address - Fax:208-233-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP252A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004383300Medicaid
ID004383300Medicaid