Provider Demographics
NPI:1063820629
Name:THRONE OF GRACE, LLC.
Entity Type:Organization
Organization Name:THRONE OF GRACE, LLC.
Other - Org Name:RENAISSANCE RANCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PINEGAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-522-6155
Mailing Address - Street 1:1165 S UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3321
Mailing Address - Country:US
Mailing Address - Phone:208-522-6155
Mailing Address - Fax:208-522-6156
Practice Address - Street 1:4460 CENTRAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-5095
Practice Address - Country:US
Practice Address - Phone:208-522-6155
Practice Address - Fax:208-522-6156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
ID261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty