Provider Demographics
NPI:1205881851
Name:ICA CATH LAB LLC
Entity type:Organization
Organization Name:ICA CATH LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LINEBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-685-2109
Mailing Address - Street 1:6140 W CURTISIAN
Mailing Address - Street 2:STE 300
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6140 W CURTISIAN
Practice Address - Street 2:STE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-322-1680
Practice Address - Fax:208-322-1695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1790182Medicare ID - Type Unspecified