Provider Demographics
NPI:1932526373
Name:MOUNTAIN FALLS MEDICAL LLC
Entity Type:Organization
Organization Name:MOUNTAIN FALLS MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAULEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:STRADLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-403-2107
Mailing Address - Street 1:1034 E 800 N
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-5304
Mailing Address - Country:US
Mailing Address - Phone:208-403-2107
Mailing Address - Fax:
Practice Address - Street 1:1995 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6493
Practice Address - Country:US
Practice Address - Phone:208-403-2107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty