Healthcare Provider Details

I. General information

NPI: 1871669903
Provider Name (Legal Business Name): FRANCISCAN LIFE CENTER NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 POCATELLO CREEK
POCATELLO ID
83206
US

IV. Provider business mailing address

PO BOX 2955 1745 POCATELLO CREEK
POCATELLO ID
83206
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-9383
  • Fax: 208-233-2707
Mailing address:
  • Phone: 208-233-9383
  • Fax: 208-233-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MARY PAUL MOLLER
Title or Position: MARRIAGE &FAMILY THERAPIST
Credential: LCPC
Phone: 208-233-9383