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IDAHO STREET MEDICAL CLINIC
NPI 1023639622
Clinic/Center - Health Service in Homedale, ID

Active since May 05, 2020CLIA 13D2165553 · Waiver
126 W. IDAHO AVE, HOMEDALE, ID 83628(208) 337-7038(208) 337-4652 Get Directions Write a Review

NPPES record last updated: May 5, 2020. Verified against the NPPES registry weekly; last sync: August 09, 2026.

About Idaho Street Medical Clinic NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

IDAHO STREET MEDICAL CLINIC (NPI 1023639622) is a healthcare organization registered as a health service in Homedale, Idaho and active in the NPI registry since May 2020. The organization holds a CLIA Waiver certificate valid through April 29, 2027 and lists Edith Mary Roe, Nurse Practitioner, as its authorized official.

NPPES Registry Identity

NPI1023639622
Entity TypeOrganization
Primary Taxonomy261QH0100X
Legal Business NameIDAHO STREET MEDICAL CLINIC
Location Address126 W. IDAHO AVEHomedale, ID 83628-8362
Mailing Address24900 Market RdParma, ID 83660-6723 · (208) 722-7744
Phone(208) 337-7038
Fax(208) 337-4652
Organization SubpartNo
Authorized OfficialEdith Mary RoeNurse Practitioner · (208) 859-4103
Enumeration DateMay 5, 2020
NPPES CertifiedMay 5, 2020
✔ NPI 1023639622 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyClinic/Center · Health ServiceAmbulatory Health Care Facilities
Taxonomy Code261QH0100X
126 W. IDAHO AVE, Homedale, ID 83628
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CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 13D2165553

Idaho Street Medical Clinic · Homedale, ID
Active · expires Apr 29, 2027
CLIA Number13D2165553
Laboratory TypeCommunity Clinic
Certificate Effective DateApril 30, 2025
Certificate Expiration DateApril 29, 2027
Laboratory DirectorEdith M. Roe Cnp
Laboratory Phone(208) 859-4103
Laboratory LocationIdaho Street Medical Clinic126 West Idaho Ave, Homedale, ID 83628
CLIA data matches this NPI record on: Address Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Idaho Street Medical Clinic's NPI number?

The NPI number for Idaho Street Medical Clinic is 1023639622. It was assigned to this organization in the NPPES registry on May 5, 2020.

Where is Idaho Street Medical Clinic located?

Idaho Street Medical Clinic is located at 126 W. Idaho Ave, Homedale, ID 83628. The listed phone number is (208) 337-7038.

What is Idaho Street Medical Clinic's specialty?

The primary specialty registered for this NPI is Clinic/Center, specializing in Health Service, with taxonomy code 261QH0100X.

Does Idaho Street Medical Clinic hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 13D2165553) is associated with this NPI, valid through April 29, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Idaho Street Medical Clinic was last updated on May 5, 2020. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 6 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.