1700076510 NPI number — MOUNTAIN HEALTH MID LEVEL

Table of content: (NPI 1700076510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700076510 NPI number — MOUNTAIN HEALTH MID LEVEL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN HEALTH MID LEVEL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700076510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
740 MCKINLEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KELLOGG
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83837-2693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-783-1267
Provider Business Mailing Address Fax Number:
208-786-4471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 MCKINLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELLOGG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83837-2693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-783-1267
Provider Business Practice Location Address Fax Number:
208-786-4471
Provider Enumeration Date:
07/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HAUGHN
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
208-783-1267

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA28 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: PA301 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA580 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002791000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: CC9834 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8A570 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010006537 . This is a "REGENCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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