Healthcare Provider Details

I. General information

NPI: 1992713432
Provider Name (Legal Business Name): POCATELLO HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY BLDG A STE. 101
POCATELLO ID
83201-2753
US

IV. Provider business mailing address

PO BOX 4168
POCATELLO ID
83205-4168
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-2001
  • Fax: 208-232-2195
Mailing address:
  • Phone: 208-234-2001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

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