Basic Information
| Provider Information | |||||||||
| NPI: | 1053584581 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEARWATER VALLEY HOSPITAL & CLINICS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MIDLEVEL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 301 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | OROFINO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835449029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084764555 | ||||||||
| FaxNumber: | 2084765385 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | OROFINO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835449029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084764555 | ||||||||
| FaxNumber: | 2084765385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEACHAM | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2084768003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 805060800 | 05 | ID | MEDICAID |