Provider Demographics
NPI:1295009785
Name:COMMUNITY CARE WEST SIDE LLC
Entity Type:Organization
Organization Name:COMMUNITY CARE WEST SIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCVEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:208-525-2600
Mailing Address - Street 1:765 S UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5093
Mailing Address - Country:US
Mailing Address - Phone:208-525-2600
Mailing Address - Fax:208-525-2611
Practice Address - Street 1:765 S UTAH AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-5093
Practice Address - Country:US
Practice Address - Phone:208-525-2600
Practice Address - Fax:208-525-2611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty