=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922377027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREVENTATIVE HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2011
-----------------------------------------------------
Last Update Date | 04/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 531 S FITNESS PL STE 100
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-6552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-853-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 531 S FITNESS PL 100
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-6552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-853-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIELLE BENNION
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-853-2273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------