NPI 1134340011

South Park, INC.

Organisation Intellectual Disabilities Intermediate Care Facility Pocatello, ID

Practice location

Address: 3875 Bannock Hwy, Pocatello, ID 83204-4405
Phone: (208) 233-6844
Mailing address: 415 S Arthur Ave, Pocatello, ID 83204-3303

Authorised official

Name: Russell C McCoy
Title: Executive Director
Phone: (208) 233-6833

Registered specialties

Intellectual Disabilities Intermediate Care Facility Primary

Nursing & Custodial Care Facilities Taxonomy 315P00000X Licence 00259800 (ID)

Other Intermediate Care Facility, Intellectual Disabilities providers in Idaho →

Registry record

NPI: 1134340011
Entity type: Organization
NPI issued: 1 May 2007
Record last updated: 22 Aug 2020

Reproduced from NPPES, the federal provider registry. The date above is when the provider last updated their own entry, not when we fetched it - a record can be years old and still current in the registry.