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NPI Code Detail

MEDICARE: CLOVER CREEK MEDICAL

MEDICARE: CLOVER CREEK MEDICAL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QP2300XPrimary Care Clinic/Center

General Provider Information

NPI Number : 1073031118
Entity Type Code : Organization
Provider Name (Legal Business Name) : CLOVER CREEK MEDICAL
Provider Business Mailing Address
First Line : PO BOX 208
Second Line :
City : BLOOMINGTON
State : ID
Zip : 83223-0208
Country : US
Telephone Number : 801-362-0157
Fax Number :
Provider Business Practice Location Address
First Line : 175 NORTH MAIN STREET
Second Line :
City : BLOOMINGTON
State : ID
Zip : 83223-8322
Country : US
Telephone Number : 801-362-0157
Fax Number : 801-362-0157
Authorized Official
Title or Position : CEO
Name : BRITTANY STRONG
Credential : NURSE PRACTITIONER
Telephone Number : 801-362-0157
Provider Enumeration Date : 09/08/2017
Last Update Date : 09/08/2017

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Directions to “CLOVER CREEK MEDICAL ” Practice Location

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