Basic Information
Provider Information | |||||||||
NPI: | 1255449013 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLEARWATER VALLEY HOSPITAL & CLINICS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 08/29/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BONNER | ||||||||
AuthorizedOfficialFirstName: | LENNE | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2084768008 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X |   | ID | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 805062500 | 05 | ID |   | MEDICAID |