Provider Demographics
NPI:1912351479
Name:ST. MARY'S HOSPITAL & CLINICS, INC.
Entity Type:Organization
Organization Name:ST. MARY'S HOSPITAL & CLINICS, INC.
Other - Org Name:SMHC DIABETES SELF-MANAGEMENT EDUCATION, TRAINING & SUPPORT PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-476-5777
Mailing Address - Street 1:PO BOX 137
Mailing Address - Street 2:701 LEWISTON STREET
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-0137
Mailing Address - Country:US
Mailing Address - Phone:208-962-3267
Mailing Address - Fax:208-962-2313
Practice Address - Street 1:701 LEWISTON STREET
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522-0137
Practice Address - Country:US
Practice Address - Phone:208-962-3267
Practice Address - Fax:208-962-2313
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S HOSPITAL & CLINICS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access