Healthcare Provider Details

I. General information

NPI: 1700076510
Provider Name (Legal Business Name): MOUNTAIN HEALTH MID LEVEL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 08/15/2008
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 TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA301
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA580
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA28
License Number StateID

VIII. Authorized Official

Name: MRS. LYNN HAUGHN
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-783-1267