Provider Demographics
NPI:1518097047
Name:GLENNS FERRY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:GLENNS FERRY HEALTH CENTER, INC.
Other - Org Name:DESERT SAGE HEALTH CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-696-7216
Mailing Address - Street 1:120 DESERT SAGE WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-1038
Mailing Address - Country:US
Mailing Address - Phone:208-875-3988
Mailing Address - Fax:208-587-3324
Practice Address - Street 1:120 DESERT SAGE WAY
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-1038
Practice Address - Country:US
Practice Address - Phone:208-587-3988
Practice Address - Fax:208-587-3324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLENNS FERRY HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-06
Last Update Date:2024-03-07
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
ID805288500Medicaid
ID86645OtherBLUE CROSS OF IDAHO
MEDICARE RAILROADOtherCP8711
ID1371720Medicare PIN
ID86645OtherBLUE CROSS OF IDAHO