Provider Demographics
NPI:1902144561
Name:CRANIOFACIAL PAIN CENTER OF IDAHO
Entity Type:Organization
Organization Name:CRANIOFACIAL PAIN CENTER OF IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:MILNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-376-3600
Mailing Address - Street 1:8119 W USTICK RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5754
Mailing Address - Country:US
Mailing Address - Phone:208-376-3600
Mailing Address - Fax:208-376-3616
Practice Address - Street 1:3400 LA TOUCHE ST.
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4208
Practice Address - Country:US
Practice Address - Phone:208-376-3600
Practice Address - Fax:208-376-3616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-16
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies