Provider Demographics
NPI:1154801595
Name:MV POCATELLO ENT, LLC
Entity type:Organization
Organization Name:MV POCATELLO ENT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NED
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLYARD
Authorized Official - Suffix:
Authorized Official - Credentials:CCO
Authorized Official - Phone:208-709-4571
Mailing Address - Street 1:333 N 18TH AVE STE B3
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3358
Mailing Address - Country:US
Mailing Address - Phone:208-232-2146
Mailing Address - Fax:
Practice Address - Street 1:333 N 18TH AVE STE B3
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-2146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-15
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty