Healthcare Provider Details

I. General information

NPI: 1699141150
Provider Name (Legal Business Name): MOUNTAIN VIEW HOSPITAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 YELLOWSTONE AVE
POCATELLO ID
83201-4203
US

IV. Provider business mailing address

2325 CORONADO ST
IDAHO FALLS ID
83404-7407
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-7246
  • Fax:
Mailing address:
  • Phone: 208-557-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number StateID

VIII. Authorized Official

Name: MR. NED HILLYARD
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 208-557-2711