Healthcare Provider Details

I. General information

NPI: 1508105248
Provider Name (Legal Business Name): ST LUKES REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2013
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 N 6TH E
MOUNTAIN HOME ID
83647-2207
US

IV. Provider business mailing address

PO BOX 2777
BOISE ID
83701-2777
US

V. Phone/Fax

Practice location:
  • Phone: 208-580-2670
  • Fax:
Mailing address:
  • Phone: 208-706-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberH5
License Number StateID

VIII. Authorized Official

Name: KATHRYN FOWLER
Title or Position: SENIOR VP, CFO
Credential:
Phone: 208-381-8717