Provider Demographics
NPI:1104173467
Name:THRONE OF GRACE, LLC.
Entity type:Organization
Organization Name:THRONE OF GRACE, LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:PINEGAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-522-6155
Mailing Address - Street 1:1165 S UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3321
Mailing Address - Country:US
Mailing Address - Phone:208-522-6155
Mailing Address - Fax:208-522-6156
Practice Address - Street 1:1165 S UTAH AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3321
Practice Address - Country:US
Practice Address - Phone:208-522-6155
Practice Address - Fax:208-522-6156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder