Provider Demographics
NPI:1417971847
Name:AMBULATORY SURGERY CENTER OF BOISE
Entity Type:Organization
Organization Name:AMBULATORY SURGERY CENTER OF BOISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLLINTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-342-4700
Mailing Address - Street 1:115 W MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7302
Mailing Address - Country:US
Mailing Address - Phone:208-342-4700
Mailing Address - Fax:208-342-4710
Practice Address - Street 1:115 W MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7302
Practice Address - Country:US
Practice Address - Phone:208-342-4700
Practice Address - Fax:208-342-4710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1870578Medicare ID - Type UnspecifiedMEDICARE NUMBER