Provider Demographics
NPI:1134462856
Name:SOUTHFORK HEALTHCARE
Entity Type:Organization
Organization Name:SOUTHFORK HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SWOPE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:208-360-1997
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:SWAN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83449-0101
Mailing Address - Country:US
Mailing Address - Phone:208-360-1997
Mailing Address - Fax:
Practice Address - Street 1:166 ELK PATH
Practice Address - Street 2:
Practice Address - City:SWAN VALLEY
Practice Address - State:ID
Practice Address - Zip Code:83449-0101
Practice Address - Country:US
Practice Address - Phone:208-360-1997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-01
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care