Provider Demographics
NPI:1609563618
Name:FIRST CARE CONCUSSION DIAGNOSTIC CLINICS OF IDAHO, LLC
Entity Type:Organization
Organization Name:FIRST CARE CONCUSSION DIAGNOSTIC CLINICS OF IDAHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-899-2053
Mailing Address - Street 1:1988 W 930 N STE D
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-4132
Mailing Address - Country:US
Mailing Address - Phone:702-403-1103
Mailing Address - Fax:385-365-5054
Practice Address - Street 1:24641 BLAZE AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-6156
Practice Address - Country:US
Practice Address - Phone:702-403-1103
Practice Address - Fax:385-365-5054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service