Provider Demographics
NPI:1952746125
Name:PEINE METABOLIC WELLNESS CENTER
Entity Type:Organization
Organization Name:PEINE METABOLIC WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-947-0925
Mailing Address - Street 1:450 W STATE ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7057
Mailing Address - Country:US
Mailing Address - Phone:208-947-0925
Mailing Address - Fax:208-947-0926
Practice Address - Street 1:450 W STATE ST
Practice Address - Street 2:SUITE 250
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7057
Practice Address - Country:US
Practice Address - Phone:208-947-0925
Practice Address - Fax:208-947-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0370133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty