Basic Information
| Provider Information | |||||||||
| NPI: | 1174629976 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTNEUF VALLEY FAMILY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4908 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
| FaxNumber: | 8449460909 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 HOSPITAL WAY STE 477 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082337832 | ||||||||
| FaxNumber: | 2082337835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DE WALL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2082337832 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 807338300 | 05 | ID | MEDICAID | 807319500 | 05 | ID | MEDICAID |