Provider Demographics
NPI:1083372890
Name:EAGLE ROCK MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:EAGLE ROCK MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENDON
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-972-0420
Mailing Address - Street 1:919 S UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3322
Mailing Address - Country:US
Mailing Address - Phone:208-425-6020
Mailing Address - Fax:
Practice Address - Street 1:919 S UTAH AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3322
Practice Address - Country:US
Practice Address - Phone:208-425-6020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-30
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty