Provider Demographics
NPI:1821239781
Name:ENDOBIOGENIC INTEGRATIVE MEDICAL CENTER
Entity Type:Organization
Organization Name:ENDOBIOGENIC INTEGRATIVE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:NICA
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:CN
Authorized Official - Phone:208-478-8400
Mailing Address - Street 1:357 W CENTER ST STE 204
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3236
Mailing Address - Country:US
Mailing Address - Phone:208-478-8400
Mailing Address - Fax:208-232-6018
Practice Address - Street 1:357 W CENTER ST STE 204
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3236
Practice Address - Country:US
Practice Address - Phone:208-478-8400
Practice Address - Fax:208-232-6018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty