Healthcare Provider Details

I. General information

NPI: 1639537012
Provider Name (Legal Business Name): GOLDER ENTERPRISES LLC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2016
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3867 E 12 N STE 4
RIGBY ID
83442-4715
US

IV. Provider business mailing address

3867 E 12 N STE 4
RIGBY ID
83442-4715
US

V. Phone/Fax

Practice location:
  • Phone: 208-754-0911
  • Fax: 208-228-0332
Mailing address:
  • Phone: 208-754-0911
  • Fax: 298-228-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-32292
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberLMSW-32292
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLMSW-32292
License Number StateID

VIII. Authorized Official

Name: MARCUS BOYD OLDER
Title or Position: OWNER
Credential: LMSW
Phone: 208-201-8881