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General NPI Number Information
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NPI Number | 1104173467
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Entity Type | Organization
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Legal Business Name | THRONE OF GRACE, LLC.
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Dates
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Enumeration Date | 08/06/2012
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Last Update Date | 12/26/2012
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Provider Practice Location Address
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Address Line | 1165 S UTAH AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3321
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Country | US
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Telephone | 208-522-6155
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Fax | 208-522-6156
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Provider Business Mailing Address
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Address Line | 1165 S UTAH AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3321
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Country | US
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Telephone | 208-522-6155
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Fax | 208-522-6156
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DAVID W PINEGAR
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Credential |
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Telephone | 208-522-6155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State | ID
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