Provider Demographics
NPI:1538503693
Name:RATHDRUM CLINIC, INC.
Entity Type:Organization
Organization Name:RATHDRUM CLINIC, INC.
Other - Org Name:RESTORED HORIZONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-819-7103
Mailing Address - Street 1:913 W CANFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9764
Mailing Address - Country:US
Mailing Address - Phone:208-819-7103
Mailing Address - Fax:208-719-0050
Practice Address - Street 1:913 W CANFIELD AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9764
Practice Address - Country:US
Practice Address - Phone:208-819-7103
Practice Address - Fax:208-719-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8126207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC147568OtherBUISNESS LICENSE FOR RATHADRUM CLINIC, INC.