Healthcare Provider Details

I. General information

NPI: 1275703241
Provider Name (Legal Business Name): NORTH CANYON MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 NORTH CANYON DRIVE
GOODING ID
83330-1858
US

IV. Provider business mailing address

267 NORTH CANYON DRIVE
GOODING ID
83330-1858
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-4433
  • Fax: 208-934-8643
Mailing address:
  • Phone: 208-934-4433
  • Fax: 208-934-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY L POWERS
Title or Position: CEO
Credential:
Phone: 208-934-4433