Healthcare Provider Details

I. General information

NPI: 1437291044
Provider Name (Legal Business Name): SOUTH PARK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S ARTHUR AVE
POCATELLO ID
83204-3303
US

IV. Provider business mailing address

415 S ARTHUR AVE
POCATELLO ID
83204-3303
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-6833
  • Fax: 208-233-6842
Mailing address:
  • Phone: 208-233-6833
  • Fax: 208-233-6842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number15
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number20
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number43
License Number StateID

VIII. Authorized Official

Name: RUSSELL C MCCOY
Title or Position: EXECUTIVE DIRECTOR
Credential: M.A.ED
Phone: 208-233-6833