Provider Demographics
NPI:1649220385
Name:ST LUKES FAMILY HEALTH, LLC
Entity Type:Organization
Organization Name:ST LUKES FAMILY HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-887-4606
Mailing Address - Street 1:3090 E GENTRY WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3501
Mailing Address - Country:US
Mailing Address - Phone:208-887-4606
Mailing Address - Fax:208-887-0810
Practice Address - Street 1:3090 E GENTRY WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3501
Practice Address - Country:US
Practice Address - Phone:208-887-4606
Practice Address - Fax:208-887-0810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty