Healthcare Provider Details

I. General information

NPI: 1811292915
Provider Name (Legal Business Name): PEARL GROUP HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2011
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 E 17TH ST SUITE A
IDAHO FALLS ID
83404-6375
US

IV. Provider business mailing address

1740 E 17TH ST SUITE A
IDAHO FALLS ID
83404-6375
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax: 208-346-7501
Mailing address:
  • Phone: 208-346-7500
  • Fax: 208-346-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberRHA-2498
License Number StateID

VIII. Authorized Official

Name: LISA BOWMAN
Title or Position: PROGRAM DIRECTOR
Credential: M.S.
Phone: 208-346-7500