Healthcare Provider Details

I. General information

NPI: 1669534756
Provider Name (Legal Business Name): MCCALL MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 STATE ST
MCCALL ID
83638-3704
US

IV. Provider business mailing address

1000 STATE ST
MCCALL ID
83638-3704
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-2221
  • Fax: 208-634-7112
Mailing address:
  • Phone: 208-634-2221
  • Fax: 208-634-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberNP454A
License Number StateID

VIII. Authorized Official

Name: MS. KAREN J KELLIE
Title or Position: PRESIDENT ADMINISTRATOR
Credential:
Phone: 208-634-2221