Basic Information
| Provider Information | |||||||||
| NPI: | 1316118466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELCOX | ||||||||
| FirstName: | JACQUIE | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | BC- HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1084 N COLE RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837048642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083770019 | ||||||||
| FaxNumber: | 2083770313 | ||||||||
| Practice Location | |||||||||
| Address1: | 1084 N COLE RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837048642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083770019 | ||||||||
| FaxNumber: | 2083770313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2008 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HA-187 | ID | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | HA-187 | 01 | ID | IDAHO HEARING AID DEALER | OTHER |