Basic Information
| Provider Information | |||||||||
| NPI: | 1114374055 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALTER KNOX MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VALOR HEALTH FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 119 N WARDWELL AVE | ||||||||
| Address2: | |||||||||
| City: | EMMETT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836173040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083656311 | ||||||||
| FaxNumber: | 2083651003 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 N WARDWELL AVE | ||||||||
| Address2: | |||||||||
| City: | EMMETT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836173040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083656311 | ||||||||
| FaxNumber: | 2083651003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2016 | ||||||||
| LastUpdateDate: | 05/20/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MALAXECHEBARRIA | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2089013204 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.