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General NPI Number Information
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NPI Number | 1588006217
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Entity Type | Organization
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Legal Business Name | SOUTH FORK SERVICES, LLC
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Dates
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Enumeration Date | 07/23/2013
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Last Update Date | 07/23/2013
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Provider Practice Location Address
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Address Line | 310 N 2ND E STE 128
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City | REXBURG
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State | ID
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Zip | 83440-1607
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Country | US
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Telephone | 208-356-5675
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Fax |
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Provider Business Mailing Address
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Address Line | 310 N 2ND E STE 128
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City | REXBURG
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State | ID
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Zip | 83440-1607
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Country | US
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Telephone | 208-356-5675
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | WADE GORDON
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Credential | LCSW
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Telephone | 208-356-5675
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LCSW 27205
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License Number State | ID
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