Healthcare Provider Details

I. General information

NPI: 1912378787
Provider Name (Legal Business Name): AAA AMERICAN HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E 17TH ST STE 5
IDAHO FALLS ID
83404-6273
US

IV. Provider business mailing address

1301 E 17TH ST STE 5
IDAHO FALLS ID
83404-6273
US

V. Phone/Fax

Practice location:
  • Phone: 208-538-3122
  • Fax:
Mailing address:
  • Phone: 208-538-3122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP 1389A
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberM4260
License Number StateID

VIII. Authorized Official

Name: ALBAN HATCH
Title or Position: MANAGER
Credential:
Phone: 208-200-3000