Healthcare Provider Details

I. General information

NPI: 1861898678
Provider Name (Legal Business Name): HEALTHSOURCE PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 6TH ST
LEWISTON ID
83501-2431
US

IV. Provider business mailing address

2134 INDUSTRIAL DR SUITE B
BOZEMAN MT
59715-2244
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-2511
  • Fax:
Mailing address:
  • Phone: 800-501-1142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SARAH MCCAULEY
Title or Position: COO
Credential:
Phone: 800-501-1142