Healthcare Provider Details

I. General information

NPI: 1639307358
Provider Name (Legal Business Name): CHAROLAIS CARE VIII, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 POLK ST E
KIMBERLY ID
83341-1618
US

IV. Provider business mailing address

2043 E CENTER ST SUITE 212
POCATELLO ID
83201-3300
US

V. Phone/Fax

Practice location:
  • Phone: 208-423-5591
  • Fax: 208-423-5651
Mailing address:
  • Phone: 208-233-4673
  • Fax: 208-233-4750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: CARLEEN WELLARD
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 208-221-2019