Provider Demographics
NPI:1760523062
Name:GEM STATE DEVELOPMENTAL CENTER LLC
Entity Type:Organization
Organization Name:GEM STATE DEVELOPMENTAL CENTER LLC
Other - Org Name:SYRINGA SOCIAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-888-5565
Mailing Address - Street 1:818 NW 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3724
Mailing Address - Country:US
Mailing Address - Phone:208-888-5566
Mailing Address - Fax:208-888-5578
Practice Address - Street 1:818 NW 15TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3724
Practice Address - Country:US
Practice Address - Phone:208-888-5566
Practice Address - Fax:208-888-5578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4GEM014251C00000X
ID3GEM043251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806276000Medicaid
ID002571100Medicaid
ID806782800Medicaid
ID002570900Medicaid