Healthcare Provider Details

I. General information

NPI: 1346799483
Provider Name (Legal Business Name): HEALING SANCTUARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 E 13TH ST
IDAHO FALLS ID
83404-5305
US

IV. Provider business mailing address

187 E 13TH ST
IDAHO FALLS ID
83404-5305
US

V. Phone/Fax

Practice location:
  • Phone: 208-497-0500
  • Fax: 208-497-0505
Mailing address:
  • Phone: 208-497-0500
  • Fax: 208-497-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BECKY WATSON
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 208-497-0500