Basic Information
| Provider Information | |||||||||
| NPI: | 1497051544 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POCATELLO HEALTH SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4168 | ||||||||
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| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082392065 | ||||||||
| FaxNumber: | 2082393754 | ||||||||
| Practice Location | |||||||||
| Address1: | 651 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082391222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 02/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | ABREU | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2082391000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.