Provider Demographics
NPI:1760730436
Name:ADA WEST DERMATOPATHOLOGY, LLC
Entity Type:Organization
Organization Name:ADA WEST DERMATOPATHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-884-3376
Mailing Address - Street 1:1618 MILLENIUM WAY
Mailing Address - Street 2:STE 220
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6439
Mailing Address - Country:US
Mailing Address - Phone:208-884-3376
Mailing Address - Fax:208-884-0858
Practice Address - Street 1:1618 MILLENIUM WAY
Practice Address - Street 2:STE 220
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6439
Practice Address - Country:US
Practice Address - Phone:208-884-3376
Practice Address - Fax:208-884-0858
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADA WEST DERMATOLOGY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-28
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP1629291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20002043OtherMEDICARE PTAN