Healthcare Provider Details

I. General information

NPI: 1790470490
Provider Name (Legal Business Name): TRINITY MOUNTAIN HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6154 N MEEKER PL STE 150
BOISE ID
83713-0211
US

IV. Provider business mailing address

440 CALLAWAY DR
CHUBBUCK ID
83202-5079
US

V. Phone/Fax

Practice location:
  • Phone: 208-705-0879
  • Fax:
Mailing address:
  • Phone: 208-705-0879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: MARIN KIRSTIN LACKEY
Title or Position: MANAGER
Credential:
Phone: 208-705-0879