Provider Demographics
NPI:1669815726
Name:PROVENTURES LLC
Entity Type:Organization
Organization Name:PROVENTURES LLC
Other - Org Name:SIDE BY SIDE FAMILY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:DUFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-419-5110
Mailing Address - Street 1:6302 E SHARPTAIL RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5922
Mailing Address - Country:US
Mailing Address - Phone:208-419-5110
Mailing Address - Fax:
Practice Address - Street 1:1422 E 17TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6285
Practice Address - Country:US
Practice Address - Phone:208-419-5110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health