Basic Information
| Provider Information | |||||||||
| NPI: | 1104339597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IDEAL TELEMEDICINE SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IDEAL OPTION, PLLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8656 W GAGE BLVD STE 301B | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993367145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092221275 | ||||||||
| FaxNumber: | 5094913031 | ||||||||
| Practice Location | |||||||||
| Address1: | 1532 ELLIS ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597158809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092221275 | ||||||||
| FaxNumber: | 5094913031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2017 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | ALLGAIER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | TODD | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5092221275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1457788275 | 05 | WV | MEDICAID |