Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 350 Main St., Grand View, Idaho |
Authorized Official Name and Position | Sharlet Wilson (EXECUTIVE ASSISTANT) |
Authorized Official Contact | 2086967203 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
120 Desert Sage Way Mountain Home ID 83647-1038 Ph: (208) 587-3988 | 350 Main St. Grand View ID 83624 Ph: (208) 834-2929 |
NPI Number | 1972633949 |
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Provider Enumeration Date | 03/07/2007 |
Last Update Date | 09/20/2024 |
Medicare PECOS PAC ID | 5496656894 |
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Medicare Enrollment ID | O20080605000685 |
Identifier | Type | State | Issuer |
---|---|---|---|
1972633949 | NPI | - | NPPES |
86645 | Other | ID | BLUE CROSS OF IDAHO |
002550600 | Medicaid | ID | |
CP8711 | Other | ID | MEDICARE RAILROAD |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (Idaho) | Primary |