Healthcare Provider Details

I. General information

NPI: 1952845075
Provider Name (Legal Business Name): LOCUST GROVE WOMENS HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 E LEIGHFIELD DR SUITE 100
MERIDIAN ID
83646-5371
US

IV. Provider business mailing address

1545 E LEIGHFIELD DR SUITE 100
MERIDIAN ID
83646-5371
US

V. Phone/Fax

Practice location:
  • Phone: 208-955-8215
  • Fax: 208-445-5899
Mailing address:
  • Phone: 208-955-8215
  • Fax: 208-445-5899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number00022842
License Number StateID

VIII. Authorized Official

Name: KATHLEEN LEWIS
Title or Position: MANAGER
Credential:
Phone: 208-955-8215