=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992898605
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST BENEDICTS FAMILY MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 414 N LINCOLN SUITE 1
-----------------------------------------------------
City | JEROME
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-324-0526
-----------------------------------------------------
Fax | 208-324-4809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 709 N LINCOLN
-----------------------------------------------------
City | JEROME
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-324-4301
-----------------------------------------------------
Fax | 208-324-3878
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. ALAN STEVENSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-324-0425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HH174
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------