Provider Demographics
NPI:1649300138
Name:BLACK CANYON FAMILY MEDICINE PC
Entity type:Organization
Organization Name:BLACK CANYON FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCGUFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-365-6311
Mailing Address - Street 1:PO BOX 16820
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83715-6820
Mailing Address - Country:US
Mailing Address - Phone:208-323-9130
Mailing Address - Fax:208-323-9070
Practice Address - Street 1:119 N WARDWELL AVE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3040
Practice Address - Country:US
Practice Address - Phone:208-365-6311
Practice Address - Fax:208-365-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty