Provider Demographics
NPI:1578724910
Name:GRAND TETON SERVICE GROUP
Entity Type:Organization
Organization Name:GRAND TETON SERVICE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:208-528-7443
Mailing Address - Street 1:PO BOX 50457
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83405-0457
Mailing Address - Country:US
Mailing Address - Phone:208-528-7443
Mailing Address - Fax:208-529-3134
Practice Address - Street 1:329 PARK AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3610
Practice Address - Country:US
Practice Address - Phone:208-528-7443
Practice Address - Fax:208-529-3134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID806915000320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities