Provider Demographics
NPI:1124825724
Name:INLANDE EMPIRE GYMNASTICS ASSOCIATION
Entity type:Organization
Organization Name:INLANDE EMPIRE GYMNASTICS ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STRATEGIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHTON NOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDERDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-691-0691
Mailing Address - Street 1:6360 N SUNSHINE ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8699
Mailing Address - Country:US
Mailing Address - Phone:208-635-5623
Mailing Address - Fax:208-601-6153
Practice Address - Street 1:6360 N SUNSHINE ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8699
Practice Address - Country:US
Practice Address - Phone:208-635-5623
Practice Address - Fax:208-601-6153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-01
Last Update Date:2025-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty