Healthcare Provider Details

I. General information

NPI: 1922377027
Provider Name (Legal Business Name): PREVENTATIVE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 S FITNESS PL STE 100
EAGLE ID
83616-6552
US

IV. Provider business mailing address

531 S FITNESS PL 100
EAGLE ID
83616-6552
US

V. Phone/Fax

Practice location:
  • Phone: 208-853-2273
  • Fax:
Mailing address:
  • Phone: 208-853-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE BENNION
Title or Position: OWNER
Credential:
Phone: 208-853-2273