Healthcare Provider Details

I. General information

NPI: 1215391297
Provider Name (Legal Business Name): PEER RECOVERY SUPPORTS OF IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

963 S ORCHARD ST SUITE 202
BOISE ID
83705-1939
US

IV. Provider business mailing address

963 S ORCHARD ST SUITE 202
BOISE ID
83705-1939
US

V. Phone/Fax

Practice location:
  • Phone: 208-352-0535
  • Fax:
Mailing address:
  • Phone: 208-352-0535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL ROBERT BIGGINS
Title or Position: DIRECTOR OF OPERATIONS
Credential: M.ED, CADC
Phone: 208-352-0535