Healthcare Provider Details

I. General information

NPI: 1346547098
Provider Name (Legal Business Name): EAGLE RIVER ORGANIZATION, IND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2011
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

494 N MERIDIAN ST
BLACKFOOT ID
83221-1627
US

IV. Provider business mailing address

494 N MERIDIAN ST
BLACKFOOT ID
83221-1627
US

V. Phone/Fax

Practice location:
  • Phone: 208-200-8888
  • Fax: 208-785-6170
Mailing address:
  • Phone: 208-200-8888
  • Fax: 208-785-6170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT A PERRENOUD
Title or Position: BOARD MEMBER
Credential:
Phone: 208-200-8888