Healthcare Provider Details

I. General information

NPI: 1205623527
Provider Name (Legal Business Name): 49 ALPHA A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 N LINCOLN AVE
JEROME ID
83338-1816
US

IV. Provider business mailing address

1102 KENYON RD
TWIN FALLS ID
83301-5648
US

V. Phone/Fax

Practice location:
  • Phone: 208-308-0158
  • Fax:
Mailing address:
  • Phone: 208-751-3013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: GLEN THORNE
Title or Position: PRESIDENT
Credential:
Phone: 208-308-0158