Provider Demographics
NPI:1770502767
Name:ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:VANCE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-232-6616
Mailing Address - Street 1:PO BOX 4788
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4788
Mailing Address - Country:US
Mailing Address - Phone:208-232-6616
Mailing Address - Fax:208-232-6618
Practice Address - Street 1:1151 HOSPITAL WAY BLDG A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2763
Practice Address - Country:US
Practice Address - Phone:208-232-6616
Practice Address - Fax:208-232-6618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1870400Medicare ID - Type UnspecifiedMEDICARE NUMBER