Basic Information
| Provider Information | |||||||||
| NPI: | 1407283443 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LUKE'S CLINIC, LLC | ||||||||
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| OtherOrganizationName: | ST LUKE'S JEROME FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 640 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837010640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087065000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 775 POLE LINE RD W | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088141000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2013 | ||||||||
| LastUpdateDate: | 09/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2083812520 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.