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MOUNTAIN STATE FAMILY MEDICINE, P.C.

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Company Details

Name: MOUNTAIN STATE FAMILY MEDICINE, P.C.
Jurisdiction: Idaho
Legal type: Professional Service Corporation (D)
Status: Inactive-Dissolved (Administrative)
Date of registration: 26 Jun 2000 (25 years ago)
Financial Date End: 30 Jun 2009
Date dissolved: 08 Sep 2009
Entity Number: 411075
Place of Formation: IDAHO
File Number: 0000411075
ZIP code: 83530
County: Idaho County
Mailing Address: 610 NORTHWEST SECOND ST GRANGEVILLE, ID 83530

National Provider Identifier

NPI Number:
1710917612

Authorized Person:

Name:
LEANNE L LEBLANC
Role:
PRESIDENT
Phone:

Taxonomy:

Selected Taxonomy:
261QP2300X - Primary Care Clinic/Center
Is Primary:
Yes

Contacts:

Fax:
2089835404

Filing

Filing Name Filing Number Filing date
Annual Report 0002758233 2008-07-11
Annual Report 0002758232 2007-04-17
Annual Report 0002758231 2006-04-24
Annual Report 0002758230 2005-04-15
Legacy Amendment 0000888916 2005-03-07

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Date of last update: 25 Sep 2024

Sources: Idaho Secretary of State