Healthcare Provider Details

I. General information

NPI: 1942227699
Provider Name (Legal Business Name): VALLEY MEDICAL CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 8TH ST
LEWISTON ID
83501-7301
US

IV. Provider business mailing address

2315 8TH ST
LEWISTON ID
83501-7301
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-1383
  • Fax: 208-746-6348
Mailing address:
  • Phone: 208-746-1383
  • Fax: 208-746-6383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number04-206454
License Number StateID

VIII. Authorized Official

Name: MR. DAVID L SCHLACTUS
Title or Position: CEO
Credential:
Phone: 208-298-3100