Provider Demographics
NPI:1093800518
Name:WESTMED MEDICAL OF IDAHO, LLC
Entity Type:Organization
Organization Name:WESTMED MEDICAL OF IDAHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-792-6014
Mailing Address - Street 1:953 W 700 N
Mailing Address - Street 2:STE 110
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5775 INDUSTRY WAY
Practice Address - Street 2:STE 2
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:84321
Practice Address - Country:US
Practice Address - Phone:208-237-6600
Practice Address - Fax:208-237-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies