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General NPI Number Information
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NPI Number | 1700898822
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Entity Type | Organization
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Legal Business Name | POCATELLO CHILDREN & ADOLESCENT CLINIC
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Dates
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Enumeration Date | 08/13/2006
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Last Update Date | 03/17/2025
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Provider Practice Location Address
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Address Line | 1151 HOSPITAL WAY BLDG F
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City | POCATELLO
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State | ID
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Zip | 83201-5091
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Country | US
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Telephone | 208-232-1443
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Fax | 208-239-3434
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Provider Business Mailing Address
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Address Line | 1151 HOSPITAL WAY BLDG F
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City | POCATELLO
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State | ID
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Zip | 83201-5091
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Country | US
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Telephone | 208-232-1443
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Fax | 208-239-3434
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JESSICA PERRY
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Credential |
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Telephone | 208-236-9600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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