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General NPI Number Information
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NPI Number | 1104665587
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Entity Type | Organization
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Legal Business Name | ASHTON MEMORIAL INC
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Dates
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Enumeration Date | 05/23/2024
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Last Update Date | 05/23/2024
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Provider Practice Location Address
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Address Line | 2935 ROLLANDET ST
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City | IDAHO FALLS
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State | ID
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Zip | 83402-4654
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Country | US
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Telephone | 208-542-2905
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Fax | 208-522-2427
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Provider Business Mailing Address
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Address Line | PO BOX 838
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City | ASHTON
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State | ID
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Zip | 83420-0838
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Country | US
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Telephone | 208-652-7461
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Fax | 208-652-7595
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Authorized Official
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Title or Position | HR DIRECTOR/COMPLIANCE OFFICER
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Name | SUZANNE BRADY
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Credential |
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Telephone | 208-652-7461
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State |
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