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General NPI Number Information
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NPI Number | 1548697006
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Entity Type | Organization
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Legal Business Name | ST. LUKE'S ELKS CHILDRENS REHAB
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Dates
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Enumeration Date | 09/30/2013
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Last Update Date | 09/30/2013
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Provider Practice Location Address
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Address Line | 405 W MYRTLE ST
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City | BOISE
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State | ID
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Zip | 83702-7658
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Country | US
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Telephone | 208-489-5880
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Fax |
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Provider Business Mailing Address
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Address Line | 405 W MYRTLE ST
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City | BOISE
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State | ID
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Zip | 83702-7658
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | COMPLIANCE AND RISK MANAGEMENT
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Name | BRENT WILSON
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Credential |
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Telephone | 208-489-4761
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 283XC2000X
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Taxonomy Name | Children's Rehabilitation Hospital
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License Number | SLP-2340
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License Number State | ID
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