Provider Demographics
NPI:1396121349
Name:ST. LUKE'S TREASURE VALLEY PEDIATRICS
Entity type:Organization
Organization Name:ST. LUKE'S TREASURE VALLEY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:LAUREN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-939-1035
Mailing Address - Street 1:450 W STATE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7055
Mailing Address - Country:US
Mailing Address - Phone:208-939-1035
Mailing Address - Fax:208-939-8970
Practice Address - Street 1:450 W STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7055
Practice Address - Country:US
Practice Address - Phone:208-939-1035
Practice Address - Fax:208-939-8970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care