Healthcare Provider Details

I. General information

NPI: 1083769798
Provider Name (Legal Business Name): COMMUNITY WELLNESS CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 N ARTHUR AVE
POCATELLO ID
83204
US

IV. Provider business mailing address

1509 N ARTHUR AVE
POCATELLO ID
83204
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-7199
  • Fax: 208-234-8084
Mailing address:
  • Phone: 208-234-7199
  • Fax: 208-234-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number000417300
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number8053791
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number000417100
License Number StateID

VIII. Authorized Official

Name: MRS. CATALINA STECKBAUER
Title or Position: OWNER, MANAGER
Credential: MS,RN
Phone: 208-234-7199