Healthcare Provider Details

I. General information

NPI: 1972035772
Provider Name (Legal Business Name): MVH PIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 YELLOWSTONE AVE
POCATELLO ID
83201-4531
US

IV. Provider business mailing address

495 YELLOWSTONE AVE
POCATELLO ID
83201-4531
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-7422
  • Fax:
Mailing address:
  • Phone: 208-478-7422
  • 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