Provider Demographics
NPI:1639772049
Name:KINGHORN HEALTH AND WELLNESS INC
Entity Type:Organization
Organization Name:KINGHORN HEALTH AND WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:S
Authorized Official - Last Name:KINGHORN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C
Authorized Official - Phone:208-520-9336
Mailing Address - Street 1:2001 S WOODRUFF AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6373
Mailing Address - Country:US
Mailing Address - Phone:208-970-2355
Mailing Address - Fax:
Practice Address - Street 1:2001 S WOODRUFF AVE STE 20
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6373
Practice Address - Country:US
Practice Address - Phone:208-970-2355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDAPRN-62114OtherSTATE