Basic Information
| Provider Information | |||||||||
| NPI: | 1134296437 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY VISTA CARE CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | VALLEY VISTA CARE SERVICES - FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 ELM ST | ||||||||
| Address2: | |||||||||
| City: | ST MARIES | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838612119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082454576 | ||||||||
| FaxNumber: | 2082452138 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 ELM ST | ||||||||
| Address2: | |||||||||
| City: | ST MARIES | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838612119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082454576 | ||||||||
| FaxNumber: | 2082452138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLS | ||||||||
| AuthorizedOfficialFirstName: | GAIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE COMPLIANCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2082454576 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M-5955 | ID | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | O-130 | ID | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.