Healthcare Provider Details

I. General information

NPI: 1942699715
Provider Name (Legal Business Name): WHOLESOME HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2015
Last Update Date: 01/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 E 17TH ST
AMMON ID
83406-6760
US

IV. Provider business mailing address

3040 E 17TH ST
AMMON ID
83406-6760
US

V. Phone/Fax

Practice location:
  • Phone: 208-557-0200
  • Fax: 208-542-5080
Mailing address:
  • Phone: 208-557-0200
  • Fax: 208-542-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-0426
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP676A
License Number StateID

VIII. Authorized Official

Name: LARAMIE LINNING WHEELER
Title or Position: OWNER
Credential: DO
Phone: 208-589-3846