Healthcare Provider Details

I. General information

NPI: 1154893378
Provider Name (Legal Business Name): THE GENSHAI TRAUMA RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 E 17TH ST STE 190
IDAHO FALLS ID
83404-6518
US

IV. Provider business mailing address

1820 E 17TH ST STE 190
IDAHO FALLS ID
83404-6518
US

V. Phone/Fax

Practice location:
  • Phone: 208-244-4384
  • Fax: 208-549-9618
Mailing address:
  • Phone: 208-244-4384
  • Fax: 208-549-9618

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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNY CHRISTINA QUIROZ
Title or Position: OWNER
Credential:
Phone: 208-406-6194