Provider Demographics
NPI:1326915000
Name:ROCKY MOUNTAIN WELLNESS CLINIC
Entity type:Organization
Organization Name:ROCKY MOUNTAIN WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KYLEE
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, CNM, WHNP
Authorized Official - Phone:208-973-1162
Mailing Address - Street 1:2065 E 17TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8042
Mailing Address - Country:US
Mailing Address - Phone:208-497-0541
Mailing Address - Fax:208-497-0873
Practice Address - Street 1:2065 E 17TH ST STE A
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8042
Practice Address - Country:US
Practice Address - Phone:208-497-0541
Practice Address - Fax:208-497-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-20
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty