=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235333576
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDAHO FALLS GROUP HOMES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4360 WANDA ST
-----------------------------------------------------
City | AMMON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83406-6878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-522-4614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 50457
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83405-0457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. REX REDDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-523-0053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 29
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------