Provider Demographics
NPI:1144341637
Name:THE PEDIATRIC AND ADOLESCENT CENTER, INC.
Entity type:Organization
Organization Name:THE PEDIATRIC AND ADOLESCENT CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SULLIVAN
Authorized Official - Last Name:BOURQUARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-322-5437
Mailing Address - Street 1:6148 N DISCOVERY WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0201
Mailing Address - Country:US
Mailing Address - Phone:208-322-5437
Mailing Address - Fax:208-322-6013
Practice Address - Street 1:6148 N DISCOVERY WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0201
Practice Address - Country:US
Practice Address - Phone:208-322-5437
Practice Address - Fax:208-322-6013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-5223173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty