Healthcare Provider Details

I. General information

NPI: 1144168881
Provider Name (Legal Business Name): ROTH FAMILY MEDICINE AND MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 HOSPITAL WAY STE 422
POCATELLO ID
83201-2744
US

IV. Provider business mailing address

444 HOSPITAL WAY STE 422
POCATELLO ID
83201-2744
US

V. Phone/Fax

Practice location:
  • Phone: 208-423-8132
  • Fax: 208-203-6420
Mailing address:
  • Phone: 208-423-8132
  • Fax: 208-203-6420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KYLE ABRAHAM ROTH
Title or Position: AUTHORIZED OFFICIAL
Credential: FNP
Phone: 208-423-8132