Provider Demographics
NPI:1649392200
Name:FAMILY PRACTICE MEDICAL
Entity Type:Organization
Organization Name:FAMILY PRACTICE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:C
Authorized Official - Last Name:AHLRICHS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-367-6030
Mailing Address - Street 1:6318 BERMUDA DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1009
Mailing Address - Country:US
Mailing Address - Phone:208-378-0070
Mailing Address - Fax:
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-367-6030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-24633104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty