Provider Demographics
NPI:1457894339
Name:MOUNTAIN WEST MEDICAL SERVICES PLLC
Entity Type:Organization
Organization Name:MOUNTAIN WEST MEDICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR. OF NURSE PRACTIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:MCRAE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, NPH, BSN
Authorized Official - Phone:208-229-8739
Mailing Address - Street 1:1067 S WELLS ST
Mailing Address - Street 2:SUITE#110
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7997
Mailing Address - Country:US
Mailing Address - Phone:208-229-8739
Mailing Address - Fax:208-895-8540
Practice Address - Street 1:1067 S WELLS ST
Practice Address - Street 2:SUITE#110
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7997
Practice Address - Country:US
Practice Address - Phone:208-229-8739
Practice Address - Fax:208-895-8540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID54169261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care