Provider Demographics
NPI:1134768393
Name:NORTH IDAHO WEIGHT LOSS, LLC.
Entity type:Organization
Organization Name:NORTH IDAHO WEIGHT LOSS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FUNCTIONAL NUTRITIONIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURCIAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-888-7077
Mailing Address - Street 1:118 N 7TH ST STE C12
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2709
Mailing Address - Country:US
Mailing Address - Phone:208-274-3611
Mailing Address - Fax:
Practice Address - Street 1:118 N 7TH ST STE C12
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2709
Practice Address - Country:US
Practice Address - Phone:208-274-3611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-05
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date: