Provider Demographics
NPI:1962666578
Name:MOUNTAIN VIEW FAMILY MEDICINE INC.
Entity Type:Organization
Organization Name:MOUNTAIN VIEW FAMILY MEDICINE INC.
Other - Org Name:MOUNTAIN VIEW FAMILY MEDICINE INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BONINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-263-9545
Mailing Address - Street 1:1309 PONDEROSA DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-8278
Mailing Address - Country:US
Mailing Address - Phone:208-263-9545
Mailing Address - Fax:208-263-9539
Practice Address - Street 1:1309 PONDEROSA DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-8278
Practice Address - Country:US
Practice Address - Phone:208-263-9545
Practice Address - Fax:208-263-9539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-13
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8424261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806356200Medicaid
ID806356200Medicaid