NPIMap

Organization Active NPI

Mangum Primary Care LLC

  • Primary Care Clinic/Center
  • Boise, ID
National Provider Identifier
1194494229
Registry record updated Sep 11, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
MANGUM PRIMARY CARE LLC
Practice address
3046 S Bown Way
Boise, ID 83706-5499
Phone
(801) 793-8124
NPI assigned
Sep 11, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 11, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Meredith Kaye Mangum, FNP-CNPI 1740663657
Title
Owner
Phone
(801) 793-8124

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X Primary

Addresses

Primary practice location

3046 S Bown Way
Boise, ID 83706-5499

Mailing address

608 S Phillippi St
Boise, ID 83705-1160
Phone (801) 793-8124

Other practice location 1

3050 N Lakeharbor Ln Ste 120
Boise, ID 83703-6917
Phone (208) 550-3456

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20241018001117 ID Part B Supplier - Clinic/Group Practice 0547706509 Receives reassigned benefits from 2 practitioners
Practice locations: Boise, ID

National Provider Directory

National Provider Directory

Locations

3046 S Bown Way
Boise, ID 83706
Phone (208) 580-8888

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1631318400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1631318400000",
    "number": "1194494229",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "608 S PHILLIPPI ST",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837051160",
            "telephone_number": "801-793-8124"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3046 S BOWN WAY",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837065499",
            "telephone_number": "801-793-8124"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3050 N Lakeharbor Ln Ste 120",
            "address_purpose": "LOCATION",
            "city": "Boise",
            "state": "ID",
            "postal_code": "837036917",
            "country_code": "US",
            "telephone_number": "208-550-3456",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MANGUM PRIMARY CARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-09-11",
        "last_updated": "2021-09-11",
        "certification_date": "2021-09-11",
        "status": "A",
        "authorized_official_last_name": "MANGUM",
        "authorized_official_first_name": "MEREDITH",
        "authorized_official_middle_name": "KAYE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "801-793-8124",
        "authorized_official_credential": "FNP-C"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Boise, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.