Provider Demographics
NPI:1659419570
Name:ST. ALPHONSUS REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ST. ALPHONSUS REGIONAL MEDICAL CENTER INC
Other - Org Name:ST. ALPHONSUS ADDICTION RECOVERY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LANNIE
Authorized Official - Last Name:CHECKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-367-7347
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-3069
Mailing Address - Fax:208-367-3002
Practice Address - Street 1:6138 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8857
Practice Address - Country:US
Practice Address - Phone:208-367-3069
Practice Address - Fax:208-367-3002
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST ALPHONSUS REG MED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-02
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YA0400X, 1041C0700X
2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1691782Medicare Oscar/Certification
ID1250802Medicare Oscar/Certification