Provider Demographics
NPI:1467621383
Name:NUTRITIONAL MEDICINE OF IDAHO
Entity Type:Organization
Organization Name:NUTRITIONAL MEDICINE OF IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:R
Authorized Official - Last Name:MACHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-343-3883
Mailing Address - Street 1:1520 W STATE ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4085
Mailing Address - Country:US
Mailing Address - Phone:208-343-3883
Mailing Address - Fax:208-287-2010
Practice Address - Street 1:1520 W STATE ST
Practice Address - Street 2:SUITE 220
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4085
Practice Address - Country:US
Practice Address - Phone:208-343-3883
Practice Address - Fax:208-287-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD043133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty