Provider Demographics
NPI:1992767800
Name:WEST VALLEY LIFELINE SERVICES
Entity type:Organization
Organization Name:WEST VALLEY LIFELINE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MYRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-455-3754
Mailing Address - Street 1:1717 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4802
Mailing Address - Country:US
Mailing Address - Phone:208-455-3754
Mailing Address - Fax:208-455-3955
Practice Address - Street 1:1717 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4802
Practice Address - Country:US
Practice Address - Phone:208-455-3754
Practice Address - Fax:208-455-3955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID332B00000X332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment