| Organization Name: | MOUNTAIN STATE FAMILY MEDICINE, PC |
| NPI Number: | 1710917612 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LEANNE L LEBLANC (PRESIDENT) |
| Mailing Address: | 610 Nw 2nd St Grangeville |
| State: | ID US |
| Postal Code: | 835301244 |
| Phone Number: | 2089835120 |
| Fax Number: | 2089835404 |
| NPI Enumeration Date: | 07/04/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |