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General NPI Number Information
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NPI Number | 1265582829
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Entity Type | Organization
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Legal Business Name | IDAHO FALLS GROUP HOMES
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 275 ASH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83402-4040
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Country | US
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Telephone | 208-523-0053
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Fax | 208-529-3134
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Provider Business Mailing Address
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Address Line | PO BOX 50457
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City | IDAHO FALLS
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State | ID
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Zip | 83405
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Country | US
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Telephone | 208-523-0053
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Fax | 208-529-3134
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. REX S REDDEN
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Credential |
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Telephone | 208-523-0053
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 71
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License Number State | ID
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