Healthcare Provider Details

I. General information

NPI: 1063613495
Provider Name (Legal Business Name): PROHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 E CENTER ST
POCATELLO ID
83201-5702
US

IV. Provider business mailing address

936 E CENTER ST
POCATELLO ID
83201-5702
US

V. Phone/Fax

Practice location:
  • Phone: 208-235-6565
  • Fax:
Mailing address:
  • Phone: 208-235-6565
  • Fax: 208-235-7624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. PAMELA ANN SINCLAIR
Title or Position: CNA OFFICE ASSISTANT
Credential:
Phone: 208-235-6565