Provider Demographics
NPI:1417330119
Name:ST. LUKE'S CANYON VIEW
Entity Type:Organization
Organization Name:ST. LUKE'S CANYON VIEW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLMER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MA
Authorized Official - Phone:208-814-7906
Mailing Address - Street 1:228 SHOUP AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5022
Mailing Address - Country:US
Mailing Address - Phone:208-814-7900
Mailing Address - Fax:
Practice Address - Street 1:228 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5022
Practice Address - Country:US
Practice Address - Phone:208-814-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID33030273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit