Provider Demographics
NPI:1205996063
Name:IDAHO MINOR EMERGENCY AND FAMILY PRACTICE PA
Entity type:Organization
Organization Name:IDAHO MINOR EMERGENCY AND FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:HOOFT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-514-4400
Mailing Address - Street 1:3041 EAST COPPER POINTE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-514-4400
Mailing Address - Fax:208-514-4404
Practice Address - Street 1:3041 EAST COPPER POINTE DRIVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-514-4400
Practice Address - Fax:208-514-4404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13D1049440OtherCLIA NUMBER