Provider Demographics
NPI:1114417029
Name:MOUNTAIN WEST SUPPORTIVE SERVICES
Entity Type:Organization
Organization Name:MOUNTAIN WEST SUPPORTIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KALLE
Authorized Official - Middle Name:STEPHANIE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:208-715-0218
Mailing Address - Street 1:1970 E 17TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8046
Mailing Address - Country:US
Mailing Address - Phone:208-715-0218
Mailing Address - Fax:208-715-0210
Practice Address - Street 1:1970 E 17TH ST STE 101
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8046
Practice Address - Country:US
Practice Address - Phone:208-715-0218
Practice Address - Fax:208-715-0210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management