MEDICARE: FAMILY AND CHILDREN'S REHABILITATIVE SERVICES

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1578602793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY AND CHILDREN'S REHABILITATIVE SERVICES

Provider Business Mailing Address
First Line	:	622 W COLLEGE AVE
Second Line	:
City	:	ST MARIES
State	:	ID
Zip	:	83861-1822
Country	:	US
Telephone Number	:	208-245-4363
Fax Number	:	208-245-4349

Provider Business Practice Location Address
First Line	:	622 W COLLEGE AVE
Second Line	:
City	:	ST MARIES
State	:	ID
Zip	:	83861-1822
Country	:	US
Telephone Number	:	208-245-4363
Fax Number	:	208-245-4349

Authorized Official
Title or Position	:	OWNER ADMINISTRATOR
Name	:	MR. BRYAN LEON GIMMESON
Credential	:
Telephone Number	:	208-771-1262

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	08/22/2020

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