Healthcare Provider Details

I. General information

NPI: 1811760275
Provider Name (Legal Business Name): MOUNTAIN HEALTH SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 ASPEN RIDGE CIR
KIMBERLY ID
83341-5511
US

IV. Provider business mailing address

3303 ASPEN RIDGE CIR
KIMBERLY ID
83341-5511
US

V. Phone/Fax

Practice location:
  • Phone: 208-420-8752
  • Fax:
Mailing address:
  • Phone: 208-420-8752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JEREMY MARC POTTER
Title or Position: OWNER
Credential:
Phone: 208-420-8752