Provider Demographics
NPI:1457984981
Name:MINI-CASSIA MISDEMEANOR
Entity Type:Organization
Organization Name:MINI-CASSIA MISDEMEANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:PREWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-878-7361
Mailing Address - Street 1:1359 HANSEN AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-1821
Mailing Address - Country:US
Mailing Address - Phone:208-878-7361
Mailing Address - Fax:208-878-2434
Practice Address - Street 1:1359 HANSEN AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1821
Practice Address - Country:US
Practice Address - Phone:208-878-7361
Practice Address - Fax:208-878-2434
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CASSIA COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory