Healthcare Provider Details

I. General information

NPI: 1447426465
Provider Name (Legal Business Name): PEARL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 17TH ST
AMMON ID
83406-6601
US

IV. Provider business mailing address

2705 E 17TH ST
AMMON ID
83406-6669
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax: 208-346-7501
Mailing address:
  • Phone: 208-346-7500
  • Fax: 208-346-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ZAKERY WARREN
Title or Position: OWNER
Credential:
Phone: 208-346-7500