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General NPI Number Information
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NPI Number | 1356577019
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Entity Type | Organization
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Legal Business Name | GRAND TETON SERVICE GROUP
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Dates
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Enumeration Date | 06/08/2009
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Last Update Date | 06/08/2009
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Provider Practice Location Address
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Address Line | 329 PARK AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3610
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Country | US
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Telephone | 208-528-7443
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Fax | 208-528-7321
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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 | 83405-0457
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Country | US
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Telephone | 208-528-7443
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Fax | 208-528-7321
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MS. LISA BOWMAN
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Credential | MASTERS/PSYCHOLOGY
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Telephone | 208-528-7443
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | RHA-313
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License Number State | ID
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