Healthcare Provider Details

I. General information

NPI: 1649847823
Provider Name (Legal Business Name): MOUNTAIN HEALTH & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 S 1ST E
REXBURG ID
83440-1902
US

IV. Provider business mailing address

16 S 1ST E
REXBURG ID
83440-1902
US

V. Phone/Fax

Practice location:
  • Phone: 208-520-2809
  • Fax: 877-316-8001
Mailing address:
  • Phone: 208-520-2809
  • Fax: 877-316-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARTIN ANGUS MANGAN
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 208-220-1057