Provider Demographics
NPI:1871190215
Name:CARDIOVASCULAR SPECIALISTS OF AMERICA, LLC
Entity Type:Organization
Organization Name:CARDIOVASCULAR SPECIALISTS OF AMERICA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:SPENCER
Authorized Official - Last Name:LONGMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-760-7707
Mailing Address - Street 1:1515 E CLARK ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 E CLARK ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4133
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGOtherPENDING