=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669534756
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCCALL MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 STATE ST
-----------------------------------------------------
City | MCCALL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83638-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-634-2221
-----------------------------------------------------
Fax | 208-634-7112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 STATE ST
-----------------------------------------------------
City | MCCALL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83638-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-634-2221
-----------------------------------------------------
Fax | 208-634-7112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT ADMINISTRATOR
-----------------------------------------------------
Name | MS. KAREN J KELLIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-634-2221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | NP454A
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------