Basic Information
| Provider Information | |||||||||
| NPI: | 1861982456 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LUKES CLINIC - TREASURE VALLEY LLC | ||||||||
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| OtherOrganizationName: | ST LUKE'S LIFESTYLES MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083812222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5155 S HOWRY LANE | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083812222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2018 | ||||||||
| LastUpdateDate: | 05/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2083812520 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. LUKE'S HEALTH SYSTEM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0901X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
No ID Information.