Provider Demographics
NPI:1073551396
Name:CLEARWATER VALLEY HOSPITAL & CLINICS INC
Entity Type:Organization
Organization Name:CLEARWATER VALLEY HOSPITAL & CLINICS INC
Other - Org Name:CLEARWATER VALLEY HOSPITAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LENNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-476-4555
Mailing Address - Street 1:301 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-9029
Mailing Address - Country:US
Mailing Address - Phone:208-476-4555
Mailing Address - Fax:208-476-5385
Practice Address - Street 1:301 CEDAR ST
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9029
Practice Address - Country:US
Practice Address - Phone:208-476-4555
Practice Address - Fax:208-476-5385
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEARWATER VALLEY HOSPITAL & CLINICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-02
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805060900Medicaid
ID805060900Medicaid