Healthcare Provider Details

I. General information

NPI: 1871745372
Provider Name (Legal Business Name): CHAROLAIS CARE II, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 10/15/2008
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

110 N 800 E
JEROME ID
83338-5724
US

V. Phone/Fax

Practice location:
  • Phone: 208-423-5591
  • Fax:
Mailing address:
  • Phone:
  • Fax: 208-904-4030

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: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 208-221-2019