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)		ID

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CP8711	OTHER	ID	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86645	OTHER	ID	BLUE CROSS OF IDAHO
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972633949
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	:	208-587-3988
Fax Number	:	208-587-3324

Provider Business Practice Location Address
First Line	:	350 MAIN ST.
Second Line	:
City	:	GRAND VIEW
State	:	ID
Zip	:	83624
Country	:	US
Telephone Number	:	208-834-2929
Fax Number	:	208-587-3324

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	09/20/2024

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