Provider Demographics
NPI:1518006113
Name:PORTNEUF RIVER CENTER
Entity Type:Organization
Organization Name:PORTNEUF RIVER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WERNER-LEAP
Authorized Official - Suffix:
Authorized Official - Credentials:CNS, NPP
Authorized Official - Phone:208-233-2998
Mailing Address - Street 1:427 N ARTHUR AVE STE B
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3006
Mailing Address - Country:US
Mailing Address - Phone:208-233-2998
Mailing Address - Fax:208-232-0881
Practice Address - Street 1:427 N ARTHUR AVE STE B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3006
Practice Address - Country:US
Practice Address - Phone:208-233-2998
Practice Address - Fax:208-232-0881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & AdolescentGroup - Single Specialty