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FREMONT FAMILY MEDICINE PC

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Company Details

Name: FREMONT FAMILY MEDICINE PC
Jurisdiction: Idaho
Legal type: Professional Service Corporation (D)
Status: Inactive-Dissolved (Administrative)
Date of registration: 07 Oct 2015 (10 years ago)
Financial Date End: 31 Oct 2017
Date dissolved: 22 Jan 2018
Entity Number: 623315
Place of Formation: IDAHO
File Number: 0000623315
ZIP code: 83445
County: Fremont County
Mailing Address: 2489 E 700 N ST ANTHONY, ID 83445

National Provider Identifier

NPI Number:
1255704177

Authorized Person:

Name:
DR. RONALD K ELLSWORTH
Role:
DOCTOR/OWNER
Phone:

Taxonomy:

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

Contacts:

Filing

Filing Name Filing Number Filing date
Legacy Amendment 0003293153 2017-11-28
Annual Report 0003293152 2016-11-21
Initial Filing 0000623315 2015-10-07

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Date of last update: 26 Sep 2024

Sources: Idaho Secretary of State