Provider Demographics
NPI:1285624064
Name:DIVISION OF VETERANS SERVICES
Entity type:Organization
Organization Name:DIVISION OF VETERANS SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPUTY CHIEF ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHANER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-780-1320
Mailing Address - Street 1:1957 ALVIN RICKEN DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2727
Mailing Address - Country:US
Mailing Address - Phone:208-236-6340
Mailing Address - Fax:208-236-6343
Practice Address - Street 1:1957 ALVIN RICKEN DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2727
Practice Address - Country:US
Practice Address - Phone:208-236-6340
Practice Address - Fax:208-236-6343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID92314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805788400Medicaid
ID995HPOtherPHARMACY LICENSE
ID92OtherNURSING FACILITY LICENSE
ID1307126OtherNCPDP
ID805755300Medicaid