Basic Information
| Provider Information | |||||||||
| NPI: | 1871719211 | ||||||||
| 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: | 2082366695 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 GARRETT WAY | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082337832 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ARZOLA | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2082337832 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
No ID Information.