Basic Information
| Provider Information | |||||||||
| NPI: | 1164469870 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST LUKE'S CANYON VIEW BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2777 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837012777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087065000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 228 SHOUP AVE W | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087346760 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO, SR VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2083812520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 8C535 | 01 | ID | BLUE CROSS 1500 PROV NUMB | OTHER | 000010006672 | 01 | ID | BLUE SHIELD 1500 PROV NUM | OTHER | 000010006673 | 01 | ID | BLUE SHIELD HOSP PROV # | OTHER | 100505262 | 01 | ID | NEVADA MEDICAID INPT PROV | OTHER | CE0659 | 01 | ID | RAILROAD 1500 PROV NUMBER | OTHER | 03269 | 01 | ID | BLUE CROSS HOSP PROV # | OTHER |