Basic Information
| Provider Information | |||||||||
| NPI: | 1669572780 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RATHDRUM CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RESTORED HORIZONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14775 N KIMO CT | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RATHDRUM | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838588762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086875627 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14775 N KIMO CT | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RATHDRUM | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838588762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086875627 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | WHITING | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2086875627 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M8126 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DA0692 | 01 | ID | RAILROAD MEDICARE | OTHER |