Healthcare Provider Details

I. General information

NPI: 1497107171
Provider Name (Legal Business Name): MONTE CACHE HIBBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N 18TH AVE
POCATELLO ID
83201-3345
US

IV. Provider business mailing address

121 N 18TH AVE
POCATELLO ID
83201-3345
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-7383
  • Fax:
Mailing address:
  • Phone: 208-234-7383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberCFH-4005-SD
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: