Provider Demographics
NPI:1063613495
Name:PROHEALTH
Entity type:Organization
Organization Name:PROHEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNA OFFICE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SINCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-235-6565
Mailing Address - Street 1:936 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5702
Mailing Address - Country:US
Mailing Address - Phone:208-235-6565
Mailing Address - Fax:208-235-7624
Practice Address - Street 1:936 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5702
Practice Address - Country:US
Practice Address - Phone:208-235-6565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0027370Medicaid
ID0027368Medicaid
ID002737000Medicaid
DE002736800Medicaid