Organization
PAYETTE LAKES MEDICAL CLINIC, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACQUELINE R. BRUNS (VP - PHYSICIAN SERVICES)
(208) 634-4061
Entity
Organization
Contact information
Practice address
211 FOREST STREET, MCCALL, ID 83638
(208) 634-2225
(208) 634-7212
Mailing address
PO BOX 1047, MCCALL, ID 83638-1047
(208) 634-2225
(208) 634-7212
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010006343
BLUE SHIELD
ID
01
—
8934-2
BLUE CROSS
ID
Enumeration date
03/08/2007
Last updated
03/11/2008
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