Healthcare Provider Details

I. General information

NPI: 1649134347
Provider Name (Legal Business Name): GOLDEN MOUNTAIN WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S WHITLEY DR STE 200
FRUITLAND ID
83619-2611
US

IV. Provider business mailing address

425 S WHITLEY DR STE 200
FRUITLAND ID
83619-2611
US

V. Phone/Fax

Practice location:
  • Phone: 208-230-7452
  • Fax: 208-230-7452
Mailing address:
  • Phone: 208-230-7452
  • Fax: 208-230-7452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: PAIGE BUNKER
Title or Position: OWNER
Credential: LCSW
Phone: 208-230-7452