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INTERMOUNTAIN FUNCTIONAL MEDICINE PLLC

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Company Details

Name: INTERMOUNTAIN FUNCTIONAL MEDICINE PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Inactive-Dissolved (Administrative)
Date of registration: 30 May 2013 (12 years ago)
Financial Date End: 31 May 2015
Date dissolved: 25 Aug 2015
Entity Number: 385437
Place of Formation: IDAHO
File Number: 0000385437
ZIP code: 83713
County: Ada County
Principal Address: 13966 W. WAINWRIGHT DR. BOISE, ID 83713

National Provider Identifier

NPI Number:
1659719177

Authorized Person:

Name:
KATHY L BOWEN
Role:
SOLE MEMBER
Phone:

Taxonomy:

Selected Taxonomy:
363LF0000X - Family Nurse Practitioner
Is Primary:
Yes

Contacts:

Fax:
2089473465

Filing

Filing Name Filing Number Filing date
Legacy Amendment 0002653165 2016-03-09
Annual Report 0002653163 2014-03-28
Initial Filing 0000385437 2013-05-30

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Date of last update: 25 Sep 2024

Sources: Idaho Secretary of State