Healthcare Provider Details

I. General information

NPI: 1174037113
Provider Name (Legal Business Name): HEALTHY FUNCTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W SUNNYSIDE RD STE 7
IDAHO FALLS ID
83402-4642
US

IV. Provider business mailing address

4270 FRONTIER DR
AMMON ID
83406-4788
US

V. Phone/Fax

Practice location:
  • Phone: 208-521-3257
  • Fax:
Mailing address:
  • Phone: 208-521-3257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH-0982
License Number StateID

VIII. Authorized Official

Name: MELANIE HILL
Title or Position: OWNER
Credential: RDH, OMT
Phone: 208-521-3257