Healthcare Provider Details

I. General information

NPI: 1427062181
Provider Name (Legal Business Name): LOST RIVERS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 HIGHLAND DR
ARCO ID
83213-5003
US

IV. Provider business mailing address

PO BOX 815
ARCO ID
83213-0815
US

V. Phone/Fax

Practice location:
  • Phone: 208-527-8206
  • Fax: 208-527-3616
Mailing address:
  • Phone: 208-527-8206
  • Fax: 208-527-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BRAD HUERTA
Title or Position: CEO
Credential:
Phone: 208-527-8206