Provider Demographics
NPI:1003907163
Name:ASHTON MEMORIAL, INC.
Entity Type:Organization
Organization Name:ASHTON MEMORIAL, INC.
Other - Org Name:YOUTH AND FAMILY RENEWAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLOGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-652-7461
Mailing Address - Street 1:PO BOX 838
Mailing Address - Street 2:700 N. 2ND STREET
Mailing Address - City:ASHTON
Mailing Address - State:ID
Mailing Address - Zip Code:83420-0838
Mailing Address - Country:US
Mailing Address - Phone:208-652-7461
Mailing Address - Fax:208-652-7595
Practice Address - Street 1:2935 ROLLANDET ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4654
Practice Address - Country:US
Practice Address - Phone:208-542-2905
Practice Address - Fax:208-522-2427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805100400Medicaid
ID807641700Medicaid
ID807195500Medicaid
ID807361800Medicaid