Healthcare Provider Details

I. General information

NPI: 1265635346
Provider Name (Legal Business Name): LIFE SPRING WOMEN'S CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 JOHN ADAMS PKWY
IDAHO FALLS ID
83401-4360
US

IV. Provider business mailing address

1660 JOHN ADAMS PKWY
IDAHO FALLS ID
83401-4360
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-8844
  • Fax:
Mailing address:
  • Phone: 208-523-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberRPA-214
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-253A
License Number StateIN

VIII. Authorized Official

Name: CRAIG Z. HALL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 208-523-8844