Provider Demographics
NPI:1770817413
Name:FAMILY CARE CLINIC
Entity Type:Organization
Organization Name:FAMILY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-321-0634
Mailing Address - Street 1:8050 W RIFLEMAN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9000
Mailing Address - Country:US
Mailing Address - Phone:208-321-0634
Mailing Address - Fax:208-321-1082
Practice Address - Street 1:8050 W RIFLEMAN ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9000
Practice Address - Country:US
Practice Address - Phone:208-321-0634
Practice Address - Fax:208-321-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002803300Medicaid