Provider Demographics
NPI:1891909636
Name:PREMIER HEALTH SYSTEMS PLLC
Entity Type:Organization
Organization Name:PREMIER HEALTH SYSTEMS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RAE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-345-3630
Mailing Address - Street 1:1149 W BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3503
Mailing Address - Country:US
Mailing Address - Phone:208-345-3630
Mailing Address - Fax:208-345-3640
Practice Address - Street 1:1149 W BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3503
Practice Address - Country:US
Practice Address - Phone:208-345-3630
Practice Address - Fax:208-345-3640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1046111N00000X
ID895294133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC9689OtherBLUE CROSS
ID000010161294OtherREGENCE BLUE SHIELD
ID000010161294OtherREGENCE BLUE SHIELD