Basic Information
| Provider Information | |||||||||
| NPI: | 1871749408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3630 E LOUISE DR | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836427975 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3630 E LOUISE DR | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836427975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083779515 | ||||||||
| FaxNumber: | 2083779517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2008 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.