Provider Demographics
NPI:1346547098
Name:EAGLE RIVER ORGANIZATION, IND
Entity Type:Organization
Organization Name:EAGLE RIVER ORGANIZATION, IND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:PERRENOUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-200-8888
Mailing Address - Street 1:494 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1627
Mailing Address - Country:US
Mailing Address - Phone:208-200-8888
Mailing Address - Fax:208-785-6170
Practice Address - Street 1:494 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1627
Practice Address - Country:US
Practice Address - Phone:208-200-8888
Practice Address - Fax:208-785-6170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty