MEDICARE: VALLEY VISTA CARE CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	M-5955	ID
2	207Q00000X	Family Medicine Physician	O-130	ID

General Provider Information

NPI Number	:	1134296437
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VALLEY VISTA CARE CORPORATION

Provider Business Mailing Address
First Line	:	820 ELM ST
Second Line	:
City	:	ST MARIES
State	:	ID
Zip	:	83861-2119
Country	:	US
Telephone Number	:	208-245-4576
Fax Number	:	208-245-2138

Provider Business Practice Location Address
First Line	:	820 ELM ST
Second Line	:
City	:	ST MARIES
State	:	ID
Zip	:	83861-2119
Country	:	US
Telephone Number	:	208-245-4576
Fax Number	:	208-245-2138

Authorized Official
Title or Position	:	CORPORATE COMPLIANCE MANAGER
Name	:	GAIL MILLS
Credential	:
Telephone Number	:	208-245-4576

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	08/22/2020

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