Healthcare Provider Details

I. General information

NPI: 1114451804
Provider Name (Legal Business Name): MVH PC SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 VISTA DR
POCATELLO ID
83201-5824
US

IV. Provider business mailing address

110 VISTA DR
POCATELLO ID
83201-5824
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-2300
  • Fax:
Mailing address:
  • Phone: 208-234-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NED HILLYARD
Title or Position: CCO
Credential:
Phone: 208-709-4571