Provider Demographics
NPI:1457656217
Name:MINI-CASSIA SURGICAL PC
Entity Type:Organization
Organization Name:MINI-CASSIA SURGICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DACLYNN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-436-8340
Mailing Address - Street 1:1218 9TH ST
Mailing Address - Street 2:STE 10
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-2207
Mailing Address - Country:US
Mailing Address - Phone:208-436-8340
Mailing Address - Fax:208-436-3956
Practice Address - Street 1:1218 9TH ST
Practice Address - Street 2:STE 10
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-2207
Practice Address - Country:US
Practice Address - Phone:208-436-8340
Practice Address - Fax:208-436-3956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7497208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty