Provider Demographics
NPI:1265607311
Name:STOCK & GARN LLP
Entity type:Organization
Organization Name:STOCK & GARN LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-678-8188
Mailing Address - Street 1:2200 PARK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2186
Mailing Address - Country:US
Mailing Address - Phone:208-678-8188
Mailing Address - Fax:208-678-3170
Practice Address - Street 1:2200 PARK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2186
Practice Address - Country:US
Practice Address - Phone:208-678-8188
Practice Address - Fax:208-678-3170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002656300Medicaid
ID804002700Medicaid