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OLDE TOWN MEDICAL

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Company Details

Name: OLDE TOWN MEDICAL
Jurisdiction: Idaho
Legal type: Assumed Business Name
Status: Active-Current
Date of registration: 23 Feb 2016 (9 years ago)
Entity Number: 558030
Place of Formation: IDAHO
File Number: 0000558030
ZIP code: 83642
County: Ada County
Mailing Address: 124 E PINE AVE MERIDIAN, ID 83642

National Provider Identifier

NPI Number:
1245690544

Authorized Person:

Name:
SUSAN E TOMEY
Role:
PROVIDER/OWNER
Phone:

Taxonomy:

Selected Taxonomy:
363LA2200X - Adult Health Nurse Practitioner
Is Primary:
Yes

Contacts:

Fax:
2088886297

Filing

Filing Name Filing Number Filing date
Initial Filing 0000558030 2016-02-23

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Date of last update: 26 Sep 2024

Sources: Idaho Secretary of State