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General NPI Number Information
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NPI Number | 1497235469
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Entity Type | Organization
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Legal Business Name | LOST RIVER WELLNESS
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Dates
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Enumeration Date | 08/18/2018
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Last Update Date | 11/28/2018
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Provider Practice Location Address
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Address Line | 3080 E GENTRY WAY STE 100
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City | MERIDIAN
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State | ID
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Zip | 83642-3060
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Country | US
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Telephone | 208-810-2318
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Fax |
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Provider Business Mailing Address
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Address Line | 3080 E GENTRY WAY STE 100
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City | MERIDIAN
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State | ID
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Zip | 83642-3060
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Country | US
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Telephone | 208-484-1447
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Fax |
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Authorized Official
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Title or Position | CHIEF BUSINESS OFFICER
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Name | JEFF BROWN
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Credential |
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Telephone | 208-484-1447
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | M11538
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License Number State | ID
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