Healthcare Provider Details

I. General information

NPI: 1497051544
Provider Name (Legal Business Name): POCATELLO HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 MEMORIAL DR
POCATELLO ID
83201-4071
US

IV. Provider business mailing address

PO BOX 4168
POCATELLO ID
83205-4168
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-1222
  • Fax:
Mailing address:
  • Phone: 208-239-2065
  • Fax: 208-239-3754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: JOHN E. ABREU
Title or Position: CFO
Credential:
Phone: 208-239-1000