MEDICARE: LIFE SPRING WOMEN'S CLINIC, P.A.

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
1	363L00000X	Nurse Practitioner	NP-253A	IN
2	363A00000X	Physician Assistant	RPA-214	ID

General Provider Information

NPI Number	:	1265635346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE SPRING WOMEN'S CLINIC, P.A.

Provider Business Mailing Address
First Line	:	1660 JOHN ADAMS PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-4360
Country	:	US
Telephone Number	:	208-523-8844
Fax Number	:

Provider Business Practice Location Address
First Line	:	1660 JOHN ADAMS PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-4360
Country	:	US
Telephone Number	:	208-523-8844
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CRAIG Z. HALL
Credential	:	M.D.
Telephone Number	:	208-523-8844

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	09/13/2007

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