Provider Demographics
NPI:1629358445
Name:WEST, MARK JAMES (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:JAMES
Last Name:WEST
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 N CLOVERDALE RD
Mailing Address - Street 2:SUITE #213
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1081
Mailing Address - Country:US
Mailing Address - Phone:208-377-0109
Mailing Address - Fax:
Practice Address - Street 1:4700 N CLOVERDALE RD
Practice Address - Street 2:SUITE #213
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1081
Practice Address - Country:US
Practice Address - Phone:208-377-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA-269237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1669601209Medicaid