Healthcare Provider Details

I. General information

NPI: 1992898605
Provider Name (Legal Business Name): ST BENEDICTS FAMILY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 N LINCOLN SUITE 1
JEROME ID
83338
US

IV. Provider business mailing address

709 N LINCOLN
JEROME ID
83338
US

V. Phone/Fax

Practice location:
  • Phone: 208-324-0526
  • Fax: 208-324-4809
Mailing address:
  • Phone: 208-324-4301
  • Fax: 208-324-3878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHH174
License Number StateID

VIII. Authorized Official

Name: MR. ALAN STEVENSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-324-0425