Provider Demographics
NPI:1215165485
Name:POCATELLO HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:POCATELLO HEALTH SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:ABREU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-239-1020
Mailing Address - Street 1:PO BOX 4168
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4168
Mailing Address - Country:US
Mailing Address - Phone:208-239-2065
Mailing Address - Fax:208-239-3754
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-2065
Practice Address - Fax:208-239-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-26
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID12282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808437000Medicaid
13690031Medicare PIN