Provider Demographics
NPI:1770649154
Name:BOUNDARY REGIONAL COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:BOUNDARY REGIONAL COMMUNITY HEALTH CENTER, INC.
Other - Org Name:KANIKSU HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-267-1718
Mailing Address - Street 1:6635 COMANCHE ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-7523
Mailing Address - Country:US
Mailing Address - Phone:208-267-1718
Mailing Address - Fax:208-267-7739
Practice Address - Street 1:6635 COMANCHE ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-7523
Practice Address - Country:US
Practice Address - Phone:208-267-1718
Practice Address - Fax:208-267-7739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID131828Medicare ID - Type UnspecifiedFQHC PROVIDER NUMBER