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General NPI Number Information
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NPI Number | 1336442607
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Entity Type | Organization
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Legal Business Name | ST LUKES CLINIC-TREASURE VALLEY LLC
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Dates
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Enumeration Date | 12/08/2010
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Last Update Date | 12/08/2022
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Provider Practice Location Address
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Address Line | 3950 17TH ST STE A
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City | BAKER CITY
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State | OR
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Zip | 97814-1300
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Country | US
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Telephone | 541-523-1001
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 640
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City | BOISE
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State | ID
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Zip | 83701-0640
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Country | US
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Telephone | 208-381-2222
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Fax |
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Authorized Official
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Title or Position | SENIOR VP, CFO
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Name | KATHRYN FOWLER
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Credential |
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Telephone | 208-381-8717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 03
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 03
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 03
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License Number State | ID
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Taxonomy #4
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 03
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License Number State | ID
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