MEDICARE: GLENNS FERRY HEALTH CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427259894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENNS FERRY HEALTH CENTER INC

Provider Business Mailing Address
First Line	:	120 DESERT SAGE WAY
Second Line	:
City	:	MOUNTAIN HOME
State	:	ID
Zip	:	83647-1038
Country	:	US
Telephone Number	:	208-696-7203
Fax Number	:	208-587-3324

Provider Business Practice Location Address
First Line	:	486 W 1ST AVE
Second Line	:
City	:	GLENNS FERRY
State	:	ID
Zip	:	83623-2701
Country	:	US
Telephone Number	:	208-366-7416
Fax Number	:	208-366-2595

Authorized Official
Title or Position	:	EXECUTIVE ASSISTANT
Name	:	SHARLET WILSON
Credential	:
Telephone Number	:	208-696-7203

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	09/20/2024

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