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500 S 11th Ave Ste 204 Pocatello ID 83201-4878 | |
(208) 232-7862 | |
Not Available |
Full Name | |
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Speciality | Clinic/Center |
Location | 500 S 11th Ave Ste 204, Pocatello, Idaho |
Authorized Official Name and Position | Mindy Stosich-benedetti (CEO) |
Authorized Official Contact | 2082327862 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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500 S 11th Ave Ste 400 Pocatello ID 83201-4880 Ph: (208) 232-7862 | 500 S 11th Ave Ste 204 Pocatello ID 83201-4878 Ph: (208) 232-7862 |
NPI Number | 1942772223 |
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Provider Enumeration Date | 12/26/2018 |
Last Update Date | 03/26/2020 |
Medicare PECOS PAC ID | 4981500931 |
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Medicare Enrollment ID | O20190329001557 |
Identifier | Type | State | Issuer |
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1942772223 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
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207Q00000X | Family Medicine | (* (Not Available)) | Secondary |
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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