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Idaho Street Medical Clinic PLLC

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Company Details

Name: Idaho Street Medical Clinic PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 14 Feb 2019 (6 years ago)
Financial Date End: 28 Feb 2026
Entity Number: 3430438
Place of Formation: IDAHO
File Number: 654768
ZIP code: 83628
County: Owyhee County
Principal Address: 126 W. IDAHO STREET HOMEDALE, ID 83628
Mailing Address: PO BOX 37 HOMEDALE, ID 83628-0037

Agent

Name Role Address
EDITH ROE Agent 24900 MARKET RD, PARMA, ID 83660

Member

Name Role Address Appointed On
EDITH ROE Member 24900 MARKET ROAD, PARMA, ID 83628 2021-10-27

National Provider Identifier

NPI Number:
1023639622
Certification Date:
2020-05-05

Authorized Person:

Name:
EDITH MARY ROE
Role:
NURSE PRACTITIONER
Phone:

Taxonomy:

Selected Taxonomy:
261QH0100X - Health Service Clinic/Center
Is Primary:
Yes

Contacts:

Fax:
2083374652

Filing

Filing Name Filing Number Filing date
Annual Report 0006067925 2025-01-13
Annual Report 0005586689 2024-02-05
Annual Report 0005061059 2023-01-11
Annual Report 0004593103 2022-02-03
Application for Reinstatement 0004461666 2021-10-27

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Date of last update: 17 May 2025

Sources: Idaho Secretary of State