Provider Demographics
NPI:1770687857
Name:ST. ALPHONSUS REG MED
Entity Type:Organization
Organization Name:ST. ALPHONSUS REG MED
Other - Org Name:ST. ALPHONSUS PSYCHIATRIC UNIT
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 1:1055 N CURTIS RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1309
Mailing Address - Country:US
Mailing Address - Phone:208-367-6230
Mailing Address - Fax:208-367-3016
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-367-6230
Practice Address - Fax:208-367-3016
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. ALPHONSUS REG MED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-11
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805034500Medicaid