Basic Information
| Provider Information | |||||||||
| NPI: | 1912515057 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH WEST, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S 11TH AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082327862 | ||||||||
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| Practice Location | |||||||||
| Address1: | 666 CHEYENNE AVE | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832043756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082327862 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2020 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | AMELIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2082327862 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH WEST, INC. | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YS0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | School | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.