Basic Information
| Provider Information | |||||||||
| NPI: | 1023189800 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFESPAN PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 MARTIN ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833014542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367090 | ||||||||
| FaxNumber: | 2087367089 | ||||||||
| Practice Location | |||||||||
| Address1: | 224 MARTIN ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833014542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367090 | ||||||||
| FaxNumber: | 2087367089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | BEVERLY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2087367090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | FNP-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP717A | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.