Provider Demographics
NPI:1205052198
Name:GEM FAMILY PRACTICE, INC
Entity type:Organization
Organization Name:GEM FAMILY PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNICE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MPA-C
Authorized Official - Phone:208-365-3455
Mailing Address - Street 1:1108 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-3535
Mailing Address - Country:US
Mailing Address - Phone:208-365-3455
Mailing Address - Fax:208-365-3422
Practice Address - Street 1:1108 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3535
Practice Address - Country:US
Practice Address - Phone:208-365-3455
Practice Address - Fax:208-365-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA 281261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00167Medicare UPIN