Healthcare Provider Details

I. General information

NPI: 1417297821
Provider Name (Legal Business Name): ST LUKES CLINIC-TREASURE VALLEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 MCKENNA DR
MOUNTAIN HOME ID
83647-2143
US

IV. Provider business mailing address

PO BOX 640
BOISE ID
83701-0640
US

V. Phone/Fax

Practice location:
  • Phone: 208-587-9703
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateID

VIII. Authorized Official

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