Basic Information
| Provider Information | |||||||||
| NPI: | 1366648487 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEUROPATHY CLINIC L.L.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 214 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | WALLACE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838732122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086822547 | ||||||||
| FaxNumber: | 2087521063 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 7TH ST | ||||||||
| Address2: | |||||||||
| City: | WALLACE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838732335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087521019 | ||||||||
| FaxNumber: | 2087521063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HULL | ||||||||
| AuthorizedOfficialFirstName: | MARIANNE | ||||||||
| AuthorizedOfficialMiddleName: | ALICE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2086822547 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | REGISTERED NURSE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N6485 | HI | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.