Provider Demographics
NPI:1497235469
Name:LOST RIVER WELLNESS
Entity Type:Organization
Organization Name:LOST RIVER WELLNESS
Other - Org Name:LOST RIVER WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF BUSINESS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-484-1447
Mailing Address - Street 1:3080 E GENTRY WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3060
Mailing Address - Country:US
Mailing Address - Phone:208-484-1447
Mailing Address - Fax:
Practice Address - Street 1:3080 E GENTRY WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3060
Practice Address - Country:US
Practice Address - Phone:208-810-2318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-18
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM11538261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health