Organization
PAYETTE LAKES MEDICAL CLINIC, PA
Active
Parent organization
PAYETTE LAKES MEDICAL CLINIC, PA
Other names
Council Mountain Medical Clinic
Organization subpart
Yes
Provider details
NPI number
Legal business name
PAYETTE LAKES MEDICAL CLINIC, PA
Authorized official
JACQUELINE R BRUNS (VP - PHYSICIAN SERVICES)
(208) 634-4061
Entity
Organization
Contact information
Practice address
101 COUNCIL AVENUE, SUITE C, COUNCIL, ID 83612
(208) 253-4915
(208) 253-4917
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
—
000010139844
BS
ID
01
—
8G122
BC
ID
Enumeration date
03/08/2007
Last updated
03/17/2008
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