Healthcare Provider Details

I. General information

NPI: 1164469870
Provider Name (Legal Business Name): ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 SHOUP AVE W
TWIN FALLS ID
83301-5022
US

IV. Provider business mailing address

PO BOX 2777
BOISE ID
83701-2777
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-6760
  • Fax:
Mailing address:
  • Phone: 208-706-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN FOWLER
Title or Position: SENIOR VP, CFO
Credential:
Phone: 208-381-8717