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General NPI Number Information
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NPI Number | 1932526373
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Entity Type | Organization
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Legal Business Name | MOUNTAIN FALLS MEDICAL LLC
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Dates
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Enumeration Date | 03/24/2014
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Last Update Date | 03/24/2014
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Provider Practice Location Address
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Address Line | 1995 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6493
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Country | US
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Telephone | 208-403-2107
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Fax |
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Provider Business Mailing Address
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Address Line | 1034 E 800 N
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City | SHELLEY
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State | ID
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Zip | 83274-5304
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Country | US
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Telephone | 208-403-2107
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. CAULEEN MARIE STRADLING
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Credential |
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Telephone | 208-403-2107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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