Healthcare Provider Details

I. General information

NPI: 1518006113
Provider Name (Legal Business Name): PORTNEUF RIVER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 N ARTHUR AVE STE B
POCATELLO ID
83204-3006
US

IV. Provider business mailing address

427 N ARTHUR AVE STE B
POCATELLO ID
83204-3006
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2998
  • Fax: 208-232-0881
Mailing address:
  • Phone: 208-233-2998
  • Fax: 208-232-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN WERNER-LEAP
Title or Position: DIRECTOR
Credential: CNS, NPP
Phone: 208-233-2998