Provider Demographics
NPI:1568005809
Name:PURE HEALTHCARE OF IDAHO LLC
Entity Type:Organization
Organization Name:PURE HEALTHCARE OF IDAHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-921-6325
Mailing Address - Street 1:4179 S RIVERBOAT RD STE 220
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-2986
Mailing Address - Country:US
Mailing Address - Phone:801-755-3387
Mailing Address - Fax:
Practice Address - Street 1:5975 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-3012
Practice Address - Country:US
Practice Address - Phone:208-488-4998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-18
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty