Provider Demographics
NPI:1316660467
Name:BRICK HOUSE RECOVERY - COEUR D'ALENE GOP
Entity type:Organization
Organization Name:BRICK HOUSE RECOVERY - COEUR D'ALENE GOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:COOMBS
Authorized Official - Suffix:
Authorized Official - Credentials:MPC
Authorized Official - Phone:801-350-1716
Mailing Address - Street 1:4727 N HIGH PRAIRIE PL
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5371
Mailing Address - Country:US
Mailing Address - Phone:801-350-1716
Mailing Address - Fax:208-286-4292
Practice Address - Street 1:3918 N SCHREIBER WAY STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8395
Practice Address - Country:US
Practice Address - Phone:801-350-1716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251J00000XAgenciesNursing Care
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1477276194OtherNPI COEUR D'ALENE