Provider Demographics
NPI:1619469525
Name:NORTH CANYON MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:NORTH CANYON MEDICAL CENTER, INC.
Other - Org Name:MEDICARE DIABETIC PREVENTION PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-934-8765
Mailing Address - Street 1:267 N CANYON DR
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-5500
Mailing Address - Country:US
Mailing Address - Phone:208-934-9886
Mailing Address - Fax:208-735-3718
Practice Address - Street 1:267 N CANYON DR
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-5500
Practice Address - Country:US
Practice Address - Phone:208-934-9886
Practice Address - Fax:208-735-3718
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH CANYON MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty