Provider Demographics
NPI:1295105567
Name:IDAHO STATE UNIVERSITY
Entity type:Organization
Organization Name:IDAHO STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE & ADMIN.
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-282-3540
Mailing Address - Street 1:921 S 8TH AVE
Mailing Address - Street 2:STOP 8288
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0001
Mailing Address - Country:US
Mailing Address - Phone:208-282-4456
Mailing Address - Fax:
Practice Address - Street 1:970 S 5TH AVE
Practice Address - Street 2:STOP 8288
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-4456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENGAL LABORATORY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory