1154089126 NPI number — POCATELLO HEALTH SERVICES, LLC

Table of content: (NPI 1154089126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154089126 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:
Provider Other Organization Name Type Code:
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:
1154089126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 BURTON HILLS BLVD STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37215-6195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-296-3594
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2240 E CENTER ST
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:
83201-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-2100
Provider Business Practice Location Address Fax Number:
208-233-3146
Provider Enumeration Date:
12/07/2021

Additional Information

Authorized Official

Authorized Official Last Name:
PETROVICH
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
EVP, GENERAL COUNSEL
Authorized Official Telephone Number:
615-296-3594

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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