Basic Information
| Provider Information | |||||||||
| NPI: | 1427057926 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH WEST, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTH WEST LAVA CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2377 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832062377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082327862 | ||||||||
| FaxNumber: | 2082327869 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 S 5TH W | ||||||||
| Address2: | |||||||||
| City: | LAVA HOT SPRINGS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087765202 | ||||||||
| FaxNumber: | 2087765614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENEDETTI | ||||||||
| AuthorizedOfficialFirstName: | MINDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2082327862 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH WEST, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M7806 | ID | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 002446100 | 05 | ID | MEDICAID | 88203 | 01 | ID | BLUE CROSS CLINIC NUMBER | OTHER |