Provider Demographics
NPI:1427537927
Name:GEM STATE FAMILY HEALTH CARE PLLC
Entity Type:Organization
Organization Name:GEM STATE FAMILY HEALTH CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:LAUNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZODROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-733-2885
Mailing Address - Street 1:496 SHOUP AVE W STE E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5043
Mailing Address - Country:US
Mailing Address - Phone:208-733-2885
Mailing Address - Fax:208-734-3352
Practice Address - Street 1:496 SHOUP AVE W STE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5043
Practice Address - Country:US
Practice Address - Phone:208-733-2885
Practice Address - Fax:208-734-3352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNP767AOtherSTATE LICENSE