Provider Demographics
NPI:1295730208
Name:ALLERGY CLINIC - IDAHO, INC.
Entity type:Organization
Organization Name:ALLERGY CLINIC - IDAHO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-388-8900
Mailing Address - Street 1:727 E RIVERPARK LN
Mailing Address - Street 2:STE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4097
Mailing Address - Country:US
Mailing Address - Phone:208-388-8900
Mailing Address - Fax:208-388-8907
Practice Address - Street 1:727 E RIVERPARK LN
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-4097
Practice Address - Country:US
Practice Address - Phone:208-388-8900
Practice Address - Fax:208-388-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1375752Medicare ID - Type Unspecified