Healthcare Provider Details

I. General information

NPI: 1245659093
Provider Name (Legal Business Name): WEST VALLEY MEDICAL GROUP SPECIALTY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 ELM STREET STE 310
CALDWELL ID
83605
US

IV. Provider business mailing address

2000 HEALTH PARK DR
BRENTWOOD TN
37027-4525
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-2035
  • Fax: 208-454-1065
Mailing address:
  • Phone: 615-373-7600
  • Fax: 866-346-1426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VB0002X
TaxonomyObesity Medicine (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: LOUIS JOSEPH
Title or Position: VP
Credential:
Phone: 615-373-7630