Healthcare Provider Details

I. General information

NPI: 1972306330
Provider Name (Legal Business Name): PEARL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 17TH ST
AMMON ID
83406-6669
US

IV. Provider business mailing address

2705 E 17TH ST
AMMON ID
83406-6669
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

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