Basic Information
| Provider Information | |||||||||
| NPI: | 1871800128 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN VIEW CENTER FOR GERIATRIC PSYCHIATRY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 275 S 5TH AVE | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832016400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082334673 | ||||||||
| FaxNumber: | 2082334750 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 POLK ST E | ||||||||
| Address2: | |||||||||
| City: | KIMBERLY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833411618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084235591 | ||||||||
| FaxNumber: | 2084235651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2010 | ||||||||
| LastUpdateDate: | 09/08/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EVERTON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2082334673 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 63 | ID | Y | Hospitals | Psychiatric Hospital |
No ID Information.