Basic Information
| Provider Information | |||||||||
| NPI: | 1770502767 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOSCOPY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4788 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082326616 | ||||||||
| FaxNumber: | 2082326618 | ||||||||
| Practice Location | |||||||||
| Address1: | 1151 HOSPITAL WAY BLDG A | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082326616 | ||||||||
| FaxNumber: | 2082326618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | VANCE | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2082326616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
No ID Information.