Healthcare Provider Details

I. General information

NPI: 1619350774
Provider Name (Legal Business Name): FAMILY HEALTH SERVICES CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 BENNETT AVE
BURLEY ID
83318-2676
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-650-7854
  • Fax: 208-578-0291
Mailing address:
  • Phone: 208-734-5036
  • Fax: 208-734-5036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number39954RP
License Number StateID

VIII. Authorized Official

Name: STACEY BLACKWOOD
Title or Position: CREDENTIALING
Credential:
Phone: 208-737-6718