Basic Information
Provider Information | |||||||||
NPI: | 1487780037 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH IDAHO WORKER CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 927 E POLSTON AVE | ||||||||
Address2: | SUITE 303 | ||||||||
City: | POST FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 838549811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086643313 | ||||||||
FaxNumber: | 2086642793 | ||||||||
Practice Location | |||||||||
Address1: | 750 N SYRINGA ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | POST FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 838545275 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087779110 | ||||||||
FaxNumber: | 2087770717 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRIS | ||||||||
AuthorizedOfficialFirstName: | SHANNON | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2086643313 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.