Provider Demographics
NPI:1215097480
Name:CLUB, INC.
Entity type:Organization
Organization Name:CLUB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-529-4673
Mailing Address - Street 1:2001 S WOODRUFF AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6374
Mailing Address - Country:US
Mailing Address - Phone:208-529-4673
Mailing Address - Fax:208-529-4676
Practice Address - Street 1:2001 S WOODRUFF AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6374
Practice Address - Country:US
Practice Address - Phone:208-529-4673
Practice Address - Fax:208-529-4676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable