Healthcare Provider Details

I. General information

NPI: 1013431816
Provider Name (Legal Business Name): GEM PREP: POCATELLO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 JESSIE CLARK LN
POCATELLO ID
83202-2787
US

IV. Provider business mailing address

PO BOX 86
DEARY ID
83823-0086
US

V. Phone/Fax

Practice location:
  • Phone: 208-877-1513
  • Fax: 208-877-1713
Mailing address:
  • Phone: 208-877-1513
  • Fax: 208-877-1713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: LORI BOGAR
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 208-877-1513