Healthcare Provider Details

I. General information

NPI: 1639211634
Provider Name (Legal Business Name): ST. BENEDICTS FAMILY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 N LINCOLN AVE
JEROME ID
83338-1851
US

IV. Provider business mailing address

709 N LINCOLN AVE
JEROME ID
83338-1851
US

V. Phone/Fax

Practice location:
  • Phone: 208-324-4301
  • Fax: 208-324-7815
Mailing address:
  • Phone: 208-324-4301
  • Fax: 208-324-7815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number366HP
License Number StateID

VIII. Authorized Official

Name: MR. BRUCE ALAN BARNES
Title or Position: PHARMACY DIRECTOR
Credential: RPH
Phone: 208-324-4301