Healthcare Provider Details

I. General information

NPI: 1659873388
Provider Name (Legal Business Name): MVH PARKWAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 PARKWAY DR
BLACKFOOT ID
83221-1667
US

IV. Provider business mailing address

1485 PARKWAY DR
BLACKFOOT ID
83221-1667
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-5100
  • Fax:
Mailing address:
  • Phone: 208-785-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NED HILLYARD
Title or Position: COMPLIANCE
Credential: CCO
Phone: 208-709-7571