Provider Demographics
NPI:1376673137
Name:GLENNS FERRY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:GLENNS FERRY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-696-7216
Mailing Address - Street 1:2280 AMERICAN LEGION BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-3142
Mailing Address - Country:US
Mailing Address - Phone:208-587-3398
Mailing Address - Fax:208-587-3324
Practice Address - Street 1:486 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:GLENNS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83623-2701
Practice Address - Country:US
Practice Address - Phone:208-366-7416
Practice Address - Fax:208-587-3324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002550500Medicaid
ID002550200Medicaid
ID1371729Medicare PIN
ID002550500Medicaid