1003907163 NPI number — ASHTON MEMORIAL, INC.

Table of content: (NPI 1003907163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003907163 NPI number — ASHTON MEMORIAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASHTON MEMORIAL, INC.
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:
YOUTH AND FAMILY RENEWAL SERVICES
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:
1003907163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 838
Provider Second Line Business Mailing Address:
700 N. 2ND STREET
Provider Business Mailing Address City Name:
ASHTON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83420-0838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-652-7461
Provider Business Mailing Address Fax Number:
208-652-7595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2935 ROLLANDET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83402-4654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-542-2905
Provider Business Practice Location Address Fax Number:
208-522-2427
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KELLOGG
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
208-652-7461

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 805100400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807641700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807195500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807361800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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