Provider Demographics
NPI:1437615952
Name:POCATELLO WELLNESS CLINIC, LLC
Entity Type:Organization
Organization Name:POCATELLO WELLNESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RENO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:208-637-9610
Mailing Address - Street 1:1155 YELLOWSTONE AVE
Mailing Address - Street 2:STE D
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4369
Mailing Address - Country:US
Mailing Address - Phone:208-637-9610
Mailing Address - Fax:208-238-6162
Practice Address - Street 1:1155 YELLOWSTONE AVE
Practice Address - Street 2:STE D
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4369
Practice Address - Country:US
Practice Address - Phone:208-637-9610
Practice Address - Fax:208-238-6162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty