Healthcare Provider Details

I. General information

NPI: 1235094632
Provider Name (Legal Business Name): PSYCHIATRIC EXCELLENCE INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 W CHRISFIELD DR
MERIDIAN ID
83646-3255
US

IV. Provider business mailing address

58 W CHRISFIELD DR
MERIDIAN ID
83646-3255
US

V. Phone/Fax

Practice location:
  • Phone: 208-419-5300
  • Fax:
Mailing address:
  • Phone: 208-419-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TONY BASTAR
Title or Position: PROVIDER
Credential: PMHNP-BC
Phone: 208-419-5300