Healthcare Provider Details

I. General information

NPI: 1104436195
Provider Name (Legal Business Name): ROCKY MOUNTAIN WOMENS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 E 17TH ST STE A
IDAHO FALLS ID
83404-8042
US

IV. Provider business mailing address

PO BOX 2578
IDAHO FALLS ID
83403-2578
US

V. Phone/Fax

Practice location:
  • Phone: 208-497-0541
  • Fax: 208-497-0873
Mailing address:
  • Phone: 208-497-0541
  • Fax: 208-497-0873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KYLEE JOHNSON
Title or Position: OWNER
Credential: CNM
Phone: 208-497-0541