Basic Information
| Provider Information | |||||||||
| NPI: | 1942227699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY MEDICAL CENTER, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835017301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087461383 | ||||||||
| FaxNumber: | 2087466383 | ||||||||
| Practice Location | |||||||||
| Address1: | 2315 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835017301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087461383 | ||||||||
| FaxNumber: | 2087466348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 12/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | SCHLACTUS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2082983100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 04-206454 | ID | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 8A950 | 01 | ID | BLUE CROSS OF ID | OTHER | 1942227699 | 01 | ID | REGENCE BLUESHIELD | OTHER | 1942227699 | 05 | ID | MEDICAID | 7081938 | 05 | WA | MEDICAID | 31250 | 01 | WA | LABOR & INDUSTRIES | OTHER |