Provider Demographics
NPI:1073843868
Name:SEQUEL TSI OF IDAHO, LLC
Entity Type:Organization
Organization Name:SEQUEL TSI OF IDAHO, LLC
Other - Org Name:MOUNTAIN HOME RTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STUPAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-419-8913
Mailing Address - Street 1:2850 INDUSTRIAL WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-3960
Mailing Address - Country:US
Mailing Address - Phone:208-587-2679
Mailing Address - Fax:208-587-2875
Practice Address - Street 1:2850 INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3960
Practice Address - Country:US
Practice Address - Phone:208-587-2679
Practice Address - Fax:208-587-2875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children