Healthcare Provider Details

I. General information

NPI: 1164539912
Provider Name (Legal Business Name): MOUNTAIN HEALTH SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 MCKINLEY AVE
KELLOGG ID
83837-2693
US

IV. Provider business mailing address

740 MCKINLEY AVE
KELLOGG ID
83837-2693
US

V. Phone/Fax

Practice location:
  • Phone: 208-783-1267
  • Fax: 208-786-4471
Mailing address:
  • Phone: 208-783-1267
  • Fax: 208-786-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM8355
License Number StateID

VIII. Authorized Official

Name: FREDERICK R HALLER
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 208-783-1267