Provider Demographics
NPI:1619270139
Name:CARRIAGE HOUSE OBSTETRICS AND GYNCECOLOGY, LLC
Entity Type:Organization
Organization Name:CARRIAGE HOUSE OBSTETRICS AND GYNCECOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-520-2636
Mailing Address - Street 1:1570 MIDWAY DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6912
Mailing Address - Country:US
Mailing Address - Phone:208-522-2557
Mailing Address - Fax:208-552-2575
Practice Address - Street 1:1570 MIDWAY DR
Practice Address - Street 2:SUITE 1
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6912
Practice Address - Country:US
Practice Address - Phone:208-522-2557
Practice Address - Fax:208-552-2575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO0578207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty