Provider Demographics
NPI:1467663328
Name:DUPUYTREN'S CENTER
Entity Type:Organization
Organization Name:DUPUYTREN'S CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-344-5628
Mailing Address - Street 1:1007 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:351 SW 9TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2639
Practice Address - Country:US
Practice Address - Phone:208-344-5628
Practice Address - Fax:208-345-2907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO14247207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE35413Medicare UPIN
OR134217Medicare ID - Type UnspecifiedDUPUYTREN'S CENTER PIN