Organization
PAYETTE LAKES MEDICAL CLINIC, PA
Active
Other names
Donnelly Medical Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
JACQUELINE R BRUNS (VP - PHYSICIAN SERVICES)
(208) 634-4061
Entity
Organization
Contact information
Practice address
454 ROSEBURY ROAD, SUITE 103, DONNELLY, ID 83615
(208) 325-4455
(208) 325-4466
Mailing address
PO BOX 1047, MCCALL, ID 83638-1047
(208) 325-4455
(208) 325-4466
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010160243
BS
ID
01
—
8N006
BC
ID
Enumeration date
03/08/2007
Last updated
03/17/2008
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