Healthcare Provider Details

I. General information

NPI: 1780242859
Provider Name (Legal Business Name): UTE HATHAWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 W POLELINE AVE
POST FALLS ID
83854-9828
US

IV. Provider business mailing address

1421 W POLELINE AVE
POST FALLS ID
83854-9828
US

V. Phone/Fax

Practice location:
  • Phone: 208-457-2887
  • Fax:
Mailing address:
  • Phone: 208-457-2887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberA0000717
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: