Provider Demographics
NPI:1811932411
Name:IDAHO FALLS CLINIC, P.A.
Entity type:Organization
Organization Name:IDAHO FALLS CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-522-7310
Mailing Address - Street 1:2001 S WOODRUFF AVE
Mailing Address - Street 2:SUITE #15
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6374
Mailing Address - Country:US
Mailing Address - Phone:208-522-7310
Mailing Address - Fax:208-524-0559
Practice Address - Street 1:2001 S WOODRUFF AVE
Practice Address - Street 2:SUITE #15
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6374
Practice Address - Country:US
Practice Address - Phone:208-522-7310
Practice Address - Fax:208-524-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP9154OtherRR MEDICARE
IDI843154OtherTRICARE
ID88468OtherBLUE CROSS
ID1370087Medicare ID - Type UnspecifiedCLINIC PROVIDER #