Provider Demographics
NPI:1154893378
Name:THE GENSHAI TRAUMA RECOVERY CENTER
Entity type:Organization
Organization Name:THE GENSHAI TRAUMA RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIROZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-406-6194
Mailing Address - Street 1:1820 E 17TH ST STE 190
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6518
Mailing Address - Country:US
Mailing Address - Phone:208-244-4384
Mailing Address - Fax:208-549-9618
Practice Address - Street 1:1820 E 17TH ST STE 190
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6518
Practice Address - Country:US
Practice Address - Phone:208-244-4384
Practice Address - Fax:208-549-9618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty