Healthcare Provider Details

I. General information

NPI: 1366831885
Provider Name (Legal Business Name): SAINT ALPHONSUS MEDICAL CENTER- ONTARIO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 SW 9TH AVE
ONTARIO OR
97914-2639
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 541-881-7480
  • Fax: 541-881-7147
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: BRIAN LANNIE CHECKETTS
Title or Position: CFO
Credential:
Phone: 208-367-7347