1215165485 NPI number — POCATELLO HEALTH SERVICES, LLC

Table of content: (NPI 1215165485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215165485 NPI number — POCATELLO HEALTH SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POCATELLO HEALTH SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PORTNEUF MEDICAL PRACTICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215165485
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4168
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83205-4168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-239-2065
Provider Business Mailing Address Fax Number:
208-239-3754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-5175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-239-2065
Provider Business Practice Location Address Fax Number:
208-239-3754
Provider Enumeration Date:
06/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ABREU
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
208-239-1020

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  12 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 808437000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com