Provider Demographics
NPI:1770183089
Name:BOISE STATE UNIVERSITY
Entity Type:Organization
Organization Name:BOISE STATE UNIVERSITY
Other - Org Name:BOISE STATE UNIVERSITY CLINICAL LABORATORY
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL LAB MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-995-3765
Mailing Address - Street 1:1910 UNIVERSITY DR # MS 1515
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83725-0002
Mailing Address - Country:US
Mailing Address - Phone:208-426-1038
Mailing Address - Fax:
Practice Address - Street 1:2133 W CESAR CHAVEZ LN RM 239
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-0001
Practice Address - Country:US
Practice Address - Phone:208-426-1038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-27
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No251K00000XAgenciesPublic Health or Welfare