Provider Demographics
NPI:1932640851
Name:DIRECT ORTHOPEDIC CARE LLC
Entity Type:Organization
Organization Name:DIRECT ORTHOPEDIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-321-4000
Mailing Address - Street 1:7979 W RIFLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9066
Mailing Address - Country:US
Mailing Address - Phone:208-321-4000
Mailing Address - Fax:208-855-0157
Practice Address - Street 1:16818 N MARKETPLACE BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5140
Practice Address - Country:US
Practice Address - Phone:208-321-4000
Practice Address - Fax:208-855-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20005078Medicare PIN