Healthcare Provider Details

I. General information

NPI: 1700206588
Provider Name (Legal Business Name): MVH BMC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S EMERSON AVE
SHELLEY ID
83274-1229
US

IV. Provider business mailing address

210 S EMERSON AVE
SHELLEY ID
83274-1229
US

V. Phone/Fax

Practice location:
  • Phone: 208-357-7404
  • Fax:
Mailing address:
  • Phone: 208-357-7404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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