Provider Demographics
NPI:1447265285
Name:MOUNTAIN WEST EAR NOSE AND THROAT, PC
Entity type:Organization
Organization Name:MOUNTAIN WEST EAR NOSE AND THROAT, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MATTHEWS
Authorized Official - Last Name:HANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-542-5414
Mailing Address - Street 1:3200 CHANNING WAY
Mailing Address - Street 2:SUITE A303
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7546
Mailing Address - Country:US
Mailing Address - Phone:208-542-5414
Mailing Address - Fax:
Practice Address - Street 1:3200 CHANNING WAY
Practice Address - Street 2:SUITE A303
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-542-5414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty