Healthcare Provider Details

I. General information

NPI: 1306543228
Provider Name (Legal Business Name): EAST IDAHO YOUTH HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 LINDEN DR
IDAHO FALLS ID
83401-4149
US

IV. Provider business mailing address

550 LINDEN DR
IDAHO FALLS ID
83401-4149
US

V. Phone/Fax

Practice location:
  • Phone: 208-360-8102
  • Fax:
Mailing address:
  • Phone: 208-360-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KAREN FAYE TORNKVIST
Title or Position: CHIEF ADMINISTRATOR
Credential:
Phone: 208-360-8102