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3101 E State St Suite 2107 Eagle ID 83616-6232 | |
| (208) 473-3003 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/center |
| Location | 3101 E State St, Eagle, Idaho |
| Authorized Official Name and Position | Anthony R. Masciotra (ASSOCIATE DEAN) |
| Authorized Official Contact | 5034945099 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
3181 Sw Sam Jackson Park Rd Mail Code Mbs Portland OR 97239-3011 Ph: (503) 494-8300 | 3101 E State St Suite 2107 Eagle ID 83616-6232 Ph: (208) 473-3003 |
| NPI Number | 1972757870 |
|---|---|
| Provider Enumeration Date | 11/05/2008 |
| Last Update Date | 12/12/2016 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972757870 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
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