Healthcare Provider Details

I. General information

NPI: 1457751471
Provider Name (Legal Business Name): ST LUKE'S ELKS CHILDREN'S REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 E LOUISE DR SUITE 255
MERIDIAN ID
83642-6302
US

IV. Provider business mailing address

914 N 18TH ST
BOISE ID
83702-3317
US

V. Phone/Fax

Practice location:
  • Phone: 208-489-5099
  • Fax:
Mailing address:
  • Phone: 434-825-5091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283XC2000X
TaxonomyChildren's Rehabilitation Hospital
License NumberOT-963
License Number StateID

VIII. Authorized Official

Name: JOHN WELSH
Title or Position: ELKS PROVIDER ENROLLMENT SPECIALIST
Credential:
Phone: 208-489-4635