Healthcare Provider Details

I. General information

NPI: 1073551396
Provider Name (Legal Business Name): CLEARWATER VALLEY HOSPITAL & CLINICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 05/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 CEDAR ST
OROFINO ID
83544-9029
US

IV. Provider business mailing address

301 CEDAR ST
OROFINO ID
83544-9029
US

V. Phone/Fax

Practice location:
  • Phone: 208-476-4555
  • Fax: 208-476-5385
Mailing address:
  • Phone: 208-476-4555
  • Fax: 208-476-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LENNE J BONNER
Title or Position: CFO
Credential:
Phone: 208-476-4555