Basic Information
| Provider Information | |||||||||
| NPI: | 1861770414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RMC MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3599 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834033599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S 3RD W | ||||||||
| Address2: | |||||||||
| City: | SODA SPRINGS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832761559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085473341 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2011 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | FLECK | ||||||||
| AuthorizedOfficialFirstName: | ROLAND | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2085252090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | M-4186 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1528162120 | 05 | ID | MEDICAID |