Provider Demographics
NPI:1255608238
Name:EAST BOISE COUNTY MEDICAL CLINIC
Entity type:Organization
Organization Name:EAST BOISE COUNTY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:JOANNE
Authorized Official - Last Name:MARICLE-KUWAHARA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-C
Authorized Official - Phone:208-392-4544
Mailing Address - Street 1:3852 HIGHWAY 21
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716
Mailing Address - Country:US
Mailing Address - Phone:208-392-4544
Mailing Address - Fax:208-392-4128
Practice Address - Street 1:3852 HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716
Practice Address - Country:US
Practice Address - Phone:208-392-4544
Practice Address - Fax:208-392-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty