Basic Information
Provider Information | |||||||||
NPI: | 1932139995 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VALLEY FAMILY HEALTH CARE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1441 NE 10TH AVE | ||||||||
Address2: |   | ||||||||
City: | PAYETTE | ||||||||
State: | ID | ||||||||
PostalCode: | 836615420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086429376 | ||||||||
FaxNumber: | 2086429598 | ||||||||
Practice Location | |||||||||
Address1: | 207 E 12TH ST | ||||||||
Address2: |   | ||||||||
City: | EMMETT | ||||||||
State: | ID | ||||||||
PostalCode: | 836173626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083651065 | ||||||||
FaxNumber: | 2083651068 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/04/2006 | ||||||||
LastUpdateDate: | 06/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PAYER ENROLLMENT SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 2086429376 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VALLEY FAMILY HEALTH CARE, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 002549000 | 01 | ID | HEALTHY CONNECTIONS | OTHER | 002548800 | 05 | ID |   | MEDICAID | FQHC | 01 | ID | COMMUNITY HEALTH CENTER | OTHER |