Basic Information
Provider Information
NPI: 1336200096
EntityType: 2
ReplacementNPI:  
OrganizationName: MCCALL MEMORIAL HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: INTEGRATIVE MEDICINE CLINIC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1000 STATE ST
Address2:  
City: MCCALL
State: ID
PostalCode: 836383704
CountryCode: US
TelephoneNumber: 2086342221
FaxNumber: 2086347112
Practice Location
Address1: 203 HEWITT ST
Address2:  
City: MCCALL
State: ID
PostalCode: 836383704
CountryCode: US
TelephoneNumber: 2086341400
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/13/2006
LastUpdateDate: 08/27/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: KELLIE
AuthorizedOfficialFirstName: KAREN
AuthorizedOfficialMiddleName: J
AuthorizedOfficialTitleorPosition: PRESIDENT ADMINISTRATOR
AuthorizedOfficialTelephone: 2086342221
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QC0050X11IDY Ambulatory Health Care FacilitiesClinic/CenterCritical Access Hospital

ID Information
IDTypeStateIssuerDescription
8M92401IDBLUE CROSS CLINIC #OTHER


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