MEDICARE: GEM PREP: MERIDIAN SOUTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1043946924
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEM PREP: MERIDIAN SOUTH LLC

Provider Business Mailing Address
First Line	:	PO BOX 86
Second Line	:
City	:	DEARY
State	:	ID
Zip	:	83823-0086
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1925 E.LAKE HAZEL RD.
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-8382
Country	:	US
Telephone Number	:	208-877-1513
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF FINANCE
Name	:	LORI BOGAR
Credential	:
Telephone Number	:	208-877-1513

Provider Enumeration Date	:	07/25/2022
Last Update Date	:	09/30/2025

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