Healthcare Provider Details

I. General information

NPI: 1235306861
Provider Name (Legal Business Name): MCCALL MEDICAL CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 02/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 FOREST ST
MCCALL ID
83638-5256
US

IV. Provider business mailing address

1000 STATE ST
MCCALL ID
83638-3704
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-1776
  • Fax: 208-634-3873
Mailing address:
  • Phone: 208-634-4061
  • Fax: 208-634-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC0050X
TaxonomyCritical Access Hospital Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MATTHEW GROENIG
Title or Position: VP FINANCE
Credential:
Phone: 208-634-4061