Provider Demographics
NPI:1538517156
Name:CC POCATELLO LLC
Entity Type:Organization
Organization Name:CC POCATELLO LLC
Other - Org Name:COMMUNITY CARE POCATELLO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-557-2700
Mailing Address - Street 1:2325 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7407
Mailing Address - Country:US
Mailing Address - Phone:208-557-2700
Mailing Address - Fax:
Practice Address - Street 1:1595 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4203
Practice Address - Country:US
Practice Address - Phone:208-233-0032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN VIEW HOSPITAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty