Provider Demographics
NPI:1760783153
Name:PEARL GROUP HOMES
Entity Type:Organization
Organization Name:PEARL GROUP HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS PSYCHOLOGY
Authorized Official - Phone:208-346-7500
Mailing Address - Street 1:1740 E 17TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6375
Mailing Address - Country:US
Mailing Address - Phone:208-346-7500
Mailing Address - Fax:208-346-7501
Practice Address - Street 1:1740 E 17TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6375
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:208-346-7501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID=========Medicaid