Provider Demographics
NPI:1952845075
Name:LOCUST GROVE WOMENS HEALTH PLLC
Entity Type:Organization
Organization Name:LOCUST GROVE WOMENS HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-955-8215
Mailing Address - Street 1:1545 E LEIGHFIELD DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5371
Mailing Address - Country:US
Mailing Address - Phone:208-955-8215
Mailing Address - Fax:208-445-5899
Practice Address - Street 1:1545 E LEIGHFIELD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5371
Practice Address - Country:US
Practice Address - Phone:208-955-8215
Practice Address - Fax:208-445-5899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID00022842207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty