Provider Demographics
NPI:1568112688
Name:ISSC FRUITLAND
Entity Type:Organization
Organization Name:ISSC FRUITLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-452-7450
Mailing Address - Street 1:811 NW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2268
Mailing Address - Country:US
Mailing Address - Phone:208-452-7450
Mailing Address - Fax:208-452-7550
Practice Address - Street 1:811 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2268
Practice Address - Country:US
Practice Address - Phone:208-452-7450
Practice Address - Fax:208-452-7550
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO SKIN SURGERY CENTER, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-24
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty